Coder II

CIBOLA GENERAL HOSPITAL

1016 E. Roosevelt Avenue

Grants, New Mexico 87020

Phone: 505-287-4446 Fax: 505-287-5309

Title: Coder II

Department:

HIM

Reports To:

Director of HIM

Direct Reports:

N/A

Date: 12/2022

Compensation:

Exempt Status:

Non-Exempt 

Range

Summary:  

Accurate assignment of ICD-10-CM/PCS, CPT-4 codes, HCPCS and Modifiers to the highest level of specificity as supported by documentation in the medical record in compliance with governmental regulations and hospital policies. Review of the quality of data and documentation and facilitate improvement. Responsible for reviewing medical records/assigned charges as necessary, for accuracy.

Essential Functions:

1. Understands and is able to apply inpatient, emergency room, observation, day surgery and clinic/outpatient coding guidelines depending upon the patient type being coded.
2. This position is able to fill in when other coders are out of office.
3. Codes RFV (Reason for visit), which are the patient’s own words on why they are presenting for services. 
4. Codes as the principal diagnosis “The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”, adhering to Cibola General Hospital’s Coding, Abstracting, Data Retrieval Policy and Procedure and AHIMA’s Standards of Ethical Coding.
5. Secondary diagnosis (es) and operative procedure(s) in the medical record for clarification, agreement, co-morbidities/complications, and additional information.
6. Identify reasons that account cannot be coded/abstracted and places cases not final coded on hold with the appropriate hold reason. Notifies HIM Director of reasons/issues with uncoded accounts.
7. Queries the attending physician utilizing the Cerner message center for further clarification or help as needed for greater specificity, clarification or correct sequencing of codes utilizing a compliant query process
8. Enters final coding and abstracting information utilizing 3M accessed through the Cerner electronic medical record (EMR).
9. Assists in training new or contract coders when the Lead Coder is unavailable.
10. Maintains a 95% coding accuracy rate or higher.
11. Codes off of the assigned coding queue(s) in Cerner but is able to run a Discharged Not Final Coded (DNFC) list daily and as necessary to identify all accounts not coded/abstracted.  
12. Codes and abstracts both discharged inpatient and outpatient charts within 3 days of discharge. Notifies HIM Director of issues affecting the ability to code discharged charts.
13. Assists HIM and PFS Directors in addressing coding errors on denied claims.
14. Helps to maintain hospital charge master (in requesting codes that do not exist in charge master, that need to be added).
15. When requested will provide support services to hospital administration on a variety of special projects related to improving operational and financial performance.
16. Performs Performance Improvement projects as needed and understands performance improvement process at Cibola General Hospital.
17. There are other duties, while not considered essential for this position, are required as part of the function of this position. 

Position Qualifications:

Education and/or Experience:

1. Current RHIT, CCS, CCS-P or CPC certification required; extensive knowledge of medical terminology, anatomy and physiology; disease processes and a minimum of 3 years of inpatient and outpatient coding experience.
2. Knowledge of ICD-10-CM/CPT/HCPCS, assigning modifiers, and prospective payment systems.
3. Strong computer skills with knowledge of Microsoft Outlook, Word, Excel and 3M.
4. Ability to work with detail.

Physical Requirements:

Physical Requirements

Occasionally

Frequently

Constantly

Walking

X

Sitting

X

Standing

X

Stooping

X

Bending

X

Kneeling

X

Crouching

X

Twisting

X

Climbing Stairs

N/A

Climbing Ladder/Scaffolding)

NA

Stretching/Reaching

X

Pushing/Pulling

X

Hearing

X

Speaking

X

Seeing (colors, brightness, details)

X

Hand-finger dexterity

X

Lifting/Carrying up to:

• 20 lbs.

X

• 30 lbs.

X

• 40 lbs.
• 75 lbs.
• 100 lbs.
• > 100 lbs.

Exposure to blood borne pathogens

Typically no exposure, but working in a healthcare facility there is limited potential.

Exposure to dust

X

Exposure to fumes

X

Exposure to noise

X

Exposure to chemicals/ hazardous materials

Typically no exposure, but working in a healthcare facility there is limited potential.

Other

N/A

ACKNOWLEDGEMENT:

I have read this job description and fully understand that the requirements set forth therein have been determined to be essential to this position (unless otherwise noted). I hereby accept the position of CODER II and agree to perform the tasks outlined in this job description in a safe manner and in accordance with the facility’s established procedures. I understand that as a result of my employment, I may be exposed to blood, body fluids, infectious diseases, air contaminants (including tobacco smoke) and hazardous chemicals, and that the facility will provide to me instructions on how to prevent and control such exposures. I further understand that I may also be exposed to the Hepatitis B Virus and that the facility will make available to me, free of charge, the Hepatitis B vaccination. I also understand I may not release/disclose protected health or facility information without proper authorization.

I understand that my employment is at-will, and thereby understand that my employment may be terminated at-will either by the facility or myself, and that such termination can be made with or without notice.

Employee Signature: ___________________________________________________________

Date:

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