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- Reviews clinical documentation and diagnostic results and applies appropriate ICD 10 CM, and CPT 4 codes.
- Codes are used for billing, internal and external reporting, research and regulatory compliance activities.
- Resolves billing related errors and assists with workflow changes and process improvement projects.
- Meets ongoing productivity and quality standard of 95% accuracy rate or better.
- Verifies that all ICD 10 codes are correctly captured.
- Verifies that physician is correctly abstracted.
- Keeps abreast of coding guideline changes.
- May identify chargeable items for facility level for given department.
- May assign codes for diagnoses and treatment for ancillary outpatient encounters.
- Abides by the standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to all official coding guidelines.
- Performs other duties as assigned.
- Additionally, the Coder III utilize0s technical coding principles and APC reimbursement expertise to assign appropriate ICD 10 CM and CPt 4 procedures.
- Assigns codes for diagnoses, treatment and procedure for multiple specialized departments, including Outpatient ancillary, Emergency Department, and Inpatient and Outpatient Surgery.
- Determines the correct principal diagnosis, co morbidities, complications, secondary conditions and surgical procedures.
- Assigns MS-DRG, Present on Admission (POA) indicators, Hospital Acquired conditions), and accurately abstracts discharge dispositions.
- Queries physicians per established policy and procedure when documentation is not clear or conflicting.
- Five years of progressive inpatient coding experience in an acute care facility.
- High school diploma or equivalent required.
- Completion of a certified coding program or graduate of a CAHIM accredited HIT program required.
- CCS Credential.
Medical Coders - Costa Mesa, United States - IMCS Group
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