Coder Outpatient- Medical Records
Shift: Full-Time (1.0)/Days/8hr shifts
The position is responsible for coding diagnoses and procedures on outpatient visits and medical records; including emergency room visits. The incumbent accurately codes diseases and procedures for patient outpatient visits, in addition to thoroughly reviewing patient medical records for the correct narrative description of the applicable diagnoses and procedures. The position converts the narrative diagnoses and procedures into ICD-10-CM, ICD-10-PCS and CPT coding via automated techniques with minimal error. The position appropriately sequences diagnoses and procedures according to current guidelines; and assigns codes to achieve optimum reimbursement. In addition the position abstracts demographic, diagnostic, and procedural information from medical documentation.
- Thoroughly reviews patient medical records for the correct narrative description of the applicable diagnoses and procedures.
- Accurately converts the narrative diagnoses and procedures into ICD-10-CM, ICD-10-PCS and CPT coding via automated techniques.
- Appropriately sequence diagnoses and procedures according to current guidelines.
- Accurately assigns codes to achieve optimum reimbursement.
- Accurately abstracts demographic, diagnostic, and procedural information from medical documentation
- Successful completion of annual competencies.
- Demonstrates commitment to professional growth and competence:
- Attends all mandatory Departmental and Hospital in-services and meetings.
- Formulates annual written goals and objectives with Supervisor.
- Seeks educational and learning experiences in identified areas of need and reviews progress through the annual review process.
- Maintains knowledge of current medical practices and coding guidelines through review of the coding literature and attendance at continuing education seminars.
- Maintains credentialing as appropriate.
- Maintains a minimum of 95% accuracy rate for coding and abstracting.
- High School graduate or equivalent, with minimum of one year post high school education required.
- Formal education in ICD-10-CM, ICD-10-PCS and CPT required:
- A minimum of 2 years coding experience required.
- Knowledge of medical terminology and anatomy and physiology required
- Thorough attention to detail and accuracy
- Credentialing as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS, CCS-P or CCA) is required.
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