Coding Specialist

Overview

Data management functions in a variety of application areas; including clinical coding, outcomes

management, and specialty registries. Reviews medical records to confirm diagnoses and apply appropriate

disease and procedure codes in ICD-10- CM, ICD-10-PCS and CPT-4 classification systems.

Abstracts and analyses records for appropriateness of documentation for assigning DRG. Enters data into computer system to produce documentation required for correct patient billing. Assists in protecting legal interests of the patient, hospital and physician. Data Entry, and retrieval of data for the purpose of statistical reporting.

Responsibilities

Examines the medical record for consistency and accuracy of identifying information; reports any discrepancies or problems to supervisor
Reviews medical record to determine all diagnoses and procedures in order to assign the appropriate codes.
Assigns and sequences ICD-10-CM diagnostic and ICD-10-PCS procedural coding on all cases and utilizes AHIMA coding guidelines
Abstracts data required by federal and state regulatory agencies (e.g., physician information, patient demographics) and enters into hospital computer system
Analyzes for optimization and DRG assignments utilizing Encoder
Identifies documentation specifics to support the diagnoses; provides the supervisor with the information to be communicated to the physicians
Carries out all quality control procedures required by the department to ensure the accuracy of data
Meets the required daily coding (ICD-10) and competency levels established for inpatient medical records (14-16) records with error rate <5%)
Meets required coding (ICD-10) and competency standards for Ambulatory Surgical records. (30-35) amb/sur records with error rate <8%)
Meets the required daily coding (ICD-10) and competency levels established for inpatient medical records (14 records with error rate <5%). Amb/surg records with error rate <8%.
Inserts tumor registry forms in record when required
Competes DOH forms for appropriate records, i.e. Alzheimer’s and CMR
Responsible for submitting DOH forms to the responsible person in a timely manner
Assigns charts to appropriate review area for quality check
Participates in the quality improvement process of the department and/or medical center
Participates in the educational programs and in-service meetings to enhance skills and development as demonstrated by record of in-service/continuing education
Maintains and enhances professional growth and development through educational programs, workshops, and professional affiliations
Maintains established departmental pollicies and procedures, objectives, compliance program, confidentiality, safety, environmental, and infection control standards
Assists in selecting, training, assigning, and monitoring staff; evaluates performance; and makes recommendations for personnel action

Qualifications

High School graduation or equivalent required.

Successful completion of a coding certificate program in ICD-10-CM, ICD-10-PCS, CPT-4 coding recognized by the American Health Information Management Association (AHIMA) and/or American Association of Professional Coders (AAPC) required. CCS, CCS-P, RHIT, or RHIA preferred.