Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form such as ICD-9-CM, ICD-9-PCS, ICDâ€“10-CM, ICD-10-PCS, HCPC Level II and CPT procedure codes that can be utilized for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
Performed by specially trained professionals, medical coding provides information for billing and reimbursement, gathering statistics, reporting and marketing. Follows established hospital and professional coding guidelines and utilizes Coding clinic, CCI, CPT Assistant, Computer Assisted Coding Technologies and other resources to ensure compliance with national and federal coding guidelines.
MAJOR DUTIES AND RESPONSIBILITIES:
Reviews the content of the medical record for hospital for outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations. Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded. Failure to properly identify diagnoses and procedures may have a dramatic negative impact upon payment received by the hospital and/or clinic.
*2. Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using ICD-9-CM, ICD-9-PCS, ICD-10-CM diagnosis and both ICD-10-PCS and CPT-4 procedure codes as required. Using the Encoder software program, determines the codes for all diagnoses and procedures. Determines their sequencing to legally maximize reimbursement. Assigns the appropriate DRG.
*3. Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines.
*4. Maintains an expert knowledge of ICD-10-CM, ICD-10 PCS and/or CPT-4 coding principles, Medicare and Pennsylvania DRGs, governmental regulations, protocols and third party requirements regarding billing and billing documentation.
*5. Queries physicians as needed to clarify documentation within the patientâ€™s record to facilitate complete and accurate coding. Understands and applies internal policy and procedure guidelines regarding how to phrase physician queries.
*6. Achieves and maintains a minimum 95% accuracy rate in hospital and professional coding while maintaining or exceeding established productivity benchmarks. This will be assessed quarterly using actual medical records and standard assessment testing.
*7. Maintains expertise in the encoder software and the EMR (EPIC) and uses these tools along with their knowledge in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded.
*8. Maintains and improves coding skills by participating in continuing coding update programs made available to the coding staff along with attending continuing education sessions as appropriate; ensures that annual coding assessment is completed and submitted to maintain certified coding credential.
*9. Assists the Coding Quality/Professional Manager with training of new coding staff related to hospital/professional coding guidelines, encoder and other software systems needed for the coding process, along with reviewing coding guidelines on an annual basis and makes recommendations for change to improve coding and data management.
COMPETENCIES AND SKILLS:
Demonstrates competency in the use of computer applications including DRG Grouper Software, Siemens, IDX, software related Medicare edits, and all coding and abstracting software/hardware currently in use by Hospital and Professional Coding Operations.
Demonstrates updated skills required for the ICD-10-CM and ICD-10-PCS coding system
Demonstrates advanced skills in extracting and analyzing clinical documentation.
Demonstrates superior knowledge of anatomy and physiology along with disease pathophysiology.
Demonstrates thorough understanding and application of new and expanded coding guidelines for both ICD-10-CM and ICD-10-PCS.
Demonstrates accurate assignment of procedural codes in the complex ICD-10-PCS code set.
Demonstrates accurate assignment of CPT 4 procedural codes and HCPC Level II code sets.
Demonstrates excellent interpersonal skills to develop relationships necessary to influence physician documentation process.
Demonstrates analytic skills necessary to clinically assess medical records.
EDUCATION AND/OR EXPERIENCE:CPC/CCS-P (Professional certification);
2. CCS/CPC-H (Hospital certification);
3. RHIT or RHIA (Hospital certification); or
Minimum three (3) yearsâ€™ experience in either hospital or professional coding in an outpatient or clinic setting required or two (2) yearsâ€™ as a Coder Apprentice with successful completion of the proficiency assessment requiring an accuracy rate of 97%.
Expert knowledge of ICD-9-CM, ICD-9-PCS, ICD-10-CM, ICD-10-PCS and CPT-4 coding principles, medical terminology, anatomy and physiology, disease processes, and Coding Clinic guidelines required.