Job Description

The Coder is responsible for accurately abstract selected data elements from each medical records for entry of coding into medical billing software. The Coder is responsible for coding reports in a timely manner. The Coder must have working knowledge of coding guidelines, demonstrates the ability to work in a fast-paced coding environment, possess basic knowledge of revenue cycle and understands the role of financial reports used to manage un-coded accounts. The Coder may be cross trained in other functions of the revenue cycle, such as charge entry.

Responsibilities:

· Assigns ICD-10-CM and CPT-4 codes according to the Official Guidelines for coding and reporting.

{Including but not limited to AHA, AMA, AHIMA, CMS, NCHS, and MLHS specific guidelines).

• Adheres to HIM policies regarding diagnosis and procedure code assignment and abstraction.
• Accurately abstracts selected data elements from each record into the clinical management system to ensure the accuracy of various ASC databases.
• Informs management of any issues or concerns regarding documentation in the medical record.
• Collaborates with coding clerk and/or supervisor to ensure all cases are coded within timeframes specified in guidelines.
• Maintains a coding compliance score of 92% to 95%.
• Maintains established productivity standards.
• Attends mandatory educational sessions and earns 10 continuing education credits per calendar year.
• Refers all coding/billing inquiries from internal or external sources to other coders for peer-review.
• Retrieves medical records to be coded and abstracted in an accurate and timely manner to ensure daily entry of charges by the billing team.
• Must be willing to attend seminars for education in coding and billing.
• Must be willing to attend software training to keep up with advances in information technology.

Qualifications & Experience:

• Minimum of two years Multi-Specialty Ambulatory Surgery Center experience is required.
• AAPC CPC Ce r tification, requ i red.
• Experience using a medical billing software. Must be familiar with Windows & MS Office.
• Minimum of 2 years experience coding ICD-10-CM, CPT-4, and DRG and/or APC assignment required
• High school graduate or equivalent.
• Completion of basic coding courses from AHIMA accredited program.

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