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- Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes.
- Utilize the encoder system to sequence the codes assigned and calculate the corresponding MS-DRG/APR DRG/APC grouper.
- Abstract patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted and encounter information prior to finalizing the encounter.
- Collaborate with the Clinical Documentation Improvement Team, Coding Team Coordinators and/or Supervisor to query for clarification of ambiguous documentation or, patient diagnostic and procedural information in the medical record.
- Be knowledgeable in the requirements of the industry with regard to Medicare and/or Managed care regulations, the International Classification of Diseases (ICD-9 and ICD-10-CM/PCS) and the Current Procedural Terminology (CPT) coding systems.
- Maintain quality and productivity standards established for the department and demonstrate proficiency in coding all types of moderate to high-complexity inpatient and outpatient records.
- Reviewing medical records and assigning diagnostic and procedural codes using ICD-9-CM/ICD-10 CM/PCS and CPT/HCPCS and any other designated coding classification system in accordance with coding guidelines.
- Assigning and sequencing codes accurately based on medical record documentation.
- Assigning the appropriate discharge disposition.
- Abstracting and entering coded data for hospital statistical and reporting requirements
- Communicating documentation improvement opportunities and coding issues to appropriate personnel for follow up and resolution
- Adhering to accuracy and productivity levels established by the department
- Communicating with co-workers, management, and hospital staff regarding clinical and reimbursement issues
- Adhering to the American Health Information Management Association's code of ethics and departmental Code of Integrity
- Maintain coding credential along with any required CEUs for ongoing credential maintenance and subject matter expertise. Qualifications
- Possession of a national certification in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS).
- Advanced-level knowledge of guidelines for the sequencing of diagnosis and procedure codes for appropriate classification systems.
- Advanced-level knowledge of anatomy, physiology, pathophysiology, pharmacology, and medical terminology to accurately translate medical record documentation into the appropriate classification system for reporting purposes.
- Experience in computerized encoding and abstracting software.
- Excellent professional verbal and written communication skills.
- At least two years of coding experience in an acute care setting, preferably a Trauma 1 teaching hospital or large healthcare delivery system.
- Ability to multi-task and work independently.
- Ability to efficiently complete work assignments and interact with coding leadership team to review and discuss documentation, coding and reimbursement issues.
- Possession of a national certification in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS) plus RHIT or RHIA certification.
- Experience with Epic electronic medical record software and 3M encoding and abstracting software.
- Five years of coding experience in an acute care setting, preferably a Trauma 1 teaching hospital or large healthcare delivery system.
HIM Coder 2 - Tampa, United States - Tampa General Hospital
Description
Job Summary
Under the general supervision of Manager and direct supervision of Supervisor, following established policies, procedures and professional guidelines, the Coder 2 will:The Coder 2 may provide guidance and assistance to Coder I staff, Apprentices and clinical practice students orienting to the department. The Coder 2 is responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital.
Essential Functions:
Required:
Preferred: