Hospital Outpatient Coder

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• Two years of continuous hospital coding/abstracting experience within the last five years.

• High School Diploma or GED and demonstrated completion of classes in medical terminology, anatomy, physiology, current ICD-CM and CPT coding conventions and disease process from an accredited program.

• Registered Health Information Technician OR Certified Professional Coder OR Certified Coding Specialist OR Certified Coding Associate OR Registered Health Information Administrator OR Certified Coding Specialist - Physician Based

• Achieve a minimum score of 75% on the Hospital Outpatient Coder test.
• Basic knowledge of and use of computer keyboard and mouse.
• Must be able to meet productivity and quality standards established for the position.
• Demonstrated ability to understand the clinical content of a health record and translate into the appropriate code.
• Demonstrated knowledge of anatomy, physiology, medical terminology and disease process to interpret general medical classifications for Hospital Ambulatory Services, Home Health/Hospice, and Hospital Observation.
• Services and CHOY services that require monitored anesthesia or conscious sedation
• Demonstrated knowledge pertaining to all guidelines that concern the coding and sequencing of diagnoses and procedures outlined in but not limited to current ICD-CM, CPT, Medicare guidelines and other sources.
• Basic knowledge of reimbursement methodologies and conventions and knowledge of rules and guidelines for the appropriate and current coding classifications.
• Must maintain coding credential and complete the required Continuing Education (CE) units.
• Must abide by the AHIMA and/or AAPC code of ethics.
• Must be willing to work in a Labor Management Partnership environment.

• N/A

Under direct supervision, the Hospital Outpatient Coder is responsible for the accurate coding and abstracting of diagnoses, conditions and procedures from medical record documentation for Hospital Ambulatory Surgery (HAS), Home Health/Hospice (if applicable), Observation (OBS) and  Hospital complex Outpatient Visit (CHOY) including capture of codes for outpatient services that require monitored anesthesia and conscious sedation.  Working from appropriate documentation, assign the appropriate codes and modifiers with ICD-CM, CPT and HCPCS Level II codes.  
All work must be performed in accordance with the rules, regulations and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD and Kaiser Permanentes organizational and institutional coding guidelines.

• Review Medical Records to identify diagnoses/procedures.
• Reviews medical record documentation to identify diagnoses/procedures to be coded Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
• Codes all appropriate diagnosis and procedures from the medical record using ICD-CM,
• CPT and HCSPCS coding classification systems.
• Responsible for the sequencing of diagnoses and procedure codes in accordance with guidelines outlined in ICD-CM, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems.
• Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting. Corrects data as needed.
• Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS, and regional and local KP policies.
• Ensures the accuracy and integrity of data abstracted and coded based on medical record documentation prior to data submission or coding completion.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information when appropriate.
• Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the position.
• Confidentiality/Security of Systems\: Maintains and complies with policies and procedures for confidentiality of all patient records.
• Demonstrates knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
• Other Duties\: Performs other duties as assigned.

Grade 565