The Coder II is responsible for performing International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding of all outpatient charts for billing, case mix, and data collection purposes and subsequently assigns outpatient surgeries and Ambulatory Patient Classifications (APC). The Coder II maintains data integrity within the hospital information systems.
Responsibilities
- Assigns ICD and CPT codes to patient diagnoses and procedures for outpatient services
- Assess the accuracy and completeness of all information provided in documentation
- Assign codes for procedures, services, and diagnosis by following set classification systems
- Identify chargeable services/items for outpatient visits and ensure that all charges are accurately billed into the system
- Code and post procedures and accurately assign CPT and ICD codes to them
- Prioritizes assignments according to established criteria and decrease pending accounts
- Contacts or queries physician when additional information or clarification is needed to code
- Reviews documentation and coding for accuracy and practices compliance with coding guidelines and protocols
- Performs compliance edits on outpatient records, and ensures discrepancies are resolved
- Reviews abstracted and statistical data for corrections and submits findings to leader
- Maintain current information/knowledge regarding coding principles and guidelines
- Completes retrospective reviews on patient charts as requested
- Assists in peer reviews on designated patient charts by utilizing established guidelines
- Utilizes the Electronic Health Record system and other related computer systems and software
- Selects appropriate assignments for coding/abstracting from work queues
- Enters coded and abstracted data appropriately for use within the hospital information system
- Assigns appropriate discharge disposition to patient encounters
- Maintains data integrity through review of the overall completeness, accuracy, and consistency of data within relevant systems
Qualifications
Education:
Certification
- Certification in CPC, CCA, CPC-P, CCS, CPC-A, RHIT, and/or RHIA.
Experience:
- 2 years as a medical coder in a hospital setting
Skills:
- Analyzing and organizing technical data
- Multitasking, time-management, and organization
- Verbal and written communication
