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Coder -- Inpatient, SDC, ER, and/or Outpatient (Req # 814) - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | wytheville, Virginia |
About this job
DEPARTMENT: Health Information Management
POSITION TITLE: Coder -- Inpatient, SDC, ER, and/or Outpatient
CLASSIFICATION:
REPORTS TO: Director, Health Information Management
I. BASIC FUNCTION
Organizes and manages the coding and abstracting of in-patient, OBV, SDC, ER and outpatient accounts of discharged and in-house patients (as available) on a daily basis. Follows hospital coding guidelines, UHDDS guidelines, coding rules as established by CMS and reported in Coding Clinics, Medicare, VHQC, American Hospital Association, and American Medical Association (for CPT-4). Complete other duties which include but not limited to the following: Chart review/analysis, filing, record assembly, analysis, and data entry, PI and monitoring activities, completion of admissions, processing 3rd party requests, completion of reports as required by the State Health Department, and answering telephone.
II. Major Responsibilities and Accountabilities
1. Completes coding of ALL in-patient, OBV, SDC, ER and outpatient records on a daily basis utilizing the bill 49 report using the ICD-9-CM, CPT-4 and HCPCS coding books and 3M encoder software to provide accurate codes and DRG assignment.
2. Un-coded charts should be worked on from oldest to newest and high dollar to lower dollar when prioritizing the daily work.
3. Follows hospital coding guidelines, UHDDS guidelines, coding rules as established by CMS and reported in Coding Clinics, Medicare, VHQC, American Hospital Association, and American Medical Association (for CPT-4 and CPT Assistant).
4. "Problem" records are routed to the Health Information Management Director and/or the responsible physician. Whenever necessary, written communication and or queries will be directed to the physician for clarification of coding problems and additional documentation. The documentation and clarification are placed in the permanent medical record.
5. Whenever possible, the records are coded to include a "MCC/CC" and if legal, the sequence may be re-arranged for optimization of DRG reimbursement, but only with the appropriate physician documentation and utilizing approved coding guidelines.
6. Completes ER charge entry process for intravenous infusions, injections and procedures utilizing designated CCS software within four day cut-off timeframe.
7. Follows up on all missing or deficient charts and completes the ER charge entry process for these records.
8. Communicates effectively with departments involved in the charge entry process to ensure accurate patient charging.
9. Monitor and manage the daily Bill 49 report for the coding, abstracting and finalization of all accounts.
10. Completed records are abstracted and billings dropped as soon as possible in order to facilitate quicker turn around time for hospital reimbursement.
11. Reviews and provides feed back to sister facility with our quarterly sister self audit process.
12. Assists with completion of abstracts for Statewide Trauma Registry for patients admitted with trauma. Must follow regulations as specified by State of Virginia . Weekly reports will be run and provided to HIM clerical staff for reporting.
13. Participate in the appeal process for all DRG or coding denials.
14. Answers telephone and responds to requests in a professional, timely manner.
15. Participate in department or hospital wide process improvement committees. Some of which may include the following:
Performance Improvement and monitoring opportunities in the Department
Completion of admission records
Processing 3rd party requests for health information
Reporting of spinal cord/head injuries to the State of Virginia Registry
Chart assembly, analysis, filing consistent with maintaining the UNIT record
Courier duties (delivering and picking up charts, reports, etc.)
III. Hospital Wide Responsibilities/Accountabilities
A. Participates in the Improving Organizational Performance (IOP) process.
B. Performs job duties in a manner that supports THE CORE VALUES, Standards of Behavior and meets performance standards.
C. Meets attendance requirements of absenteeism and lateness.
D. Attends mandatory in-services.
E. Adheres to hospital policies supporting patient rights.
F. Participates in development and attainment of department and/or WCCH Goals.
G. Reports any suspected violations of Corporate Compliance to an immediate supervisor, Corporate Compliance Officer, or the Compliance Hot-Line.
H. Adheres to WCCH policies and procedures regarding privacy and security of health information (HIPAA).
I. Works collaboratively to provide a safe environment for not only the patient, but staff and visitors.
IV. Qualifications (R) = Required (P) = Preferred
A. Education
1. (R) High school diploma or equivalent and Associates of Science in HIM field, and/or RHIT and/or CCS; and, at least three years' acute hospital inpatient, OBV, SDC, ER and outpatient coding experience and practice of medical records
2. (R) Must possess strong communication skills in order to effectively communicate with the Medical Staff
3. (R) Well-versed in medical terminology, anatomy, and physiology, ICD-9-CM and CPT-4 coding guidelines and techniques. Knowledge of DRG's, MS DRGs, PPS, APC's, CMS --Medicare and Medicaid regulations,
B. Experience
(R) 1. 1 to 3 years of acute hospital coding experience
(P) 1. 3 to 5 years of acute hospital coding and extensive MS DRG knowledge
C. Licensures/Certifications
(R) 1. RHIA, RHIT or CCS
V. Physical Demands
The physical demands of this position include; extended periods of sitting and keyboarding. In addition, one must be able to walk, stand, stretch, bend, stoop, and may be required to use the stairs. Hearing acuity and finger dexterity are required for transcription/keyboarding. The employee must be able to speak and communicate clearly. Hand-eye coordination is necessary to operate computers and various pieces of office equipment. One may be required to lift objects suitable for body strength and size up to 50 pounds. This may include above and over-the head lifting during the filing process.
IV. WORKING CONDITIONS
Works in an office environment where there is minimal discomfort due to dust, dirt or excessive noise. Requires the ability to: be mobile, move to all areas of the department and facility, be able to lift objects weighing 10-50 pounds at least, consistent with normal office work using lifting techniques demonstrated/discussed in orientation.
A. Education
1. (R) RHIT and/or CCS; and, at least one year acute hospital inpatient, OBV, SDC, ER and outpatient coding experience and practice of medical records
2. (R) Must possess strong communication skills in order to effectively communicate with the Medical Staff
3. (R) Well-versed in medical terminology, anatomy, and physiology, ICD-9-CM and CPT-4 coding guidelines and techniques. Knowledge of DRG's, MS DRGs, PPS, APC's, CMS --Medicare and Medicaid regulations,
B. Experience
(R) 1. 1 acute hospital coding experience
(P) 1. 1 to 3 years of acute hospital coding and extensive MS DRG knowledge
C. Licensures/Certifications
(R) 1. RHIA, RHIT or CCS
POSITION TITLE: Coder -- Inpatient, SDC, ER, and/or Outpatient
CLASSIFICATION:
REPORTS TO: Director, Health Information Management
I. BASIC FUNCTION
Organizes and manages the coding and abstracting of in-patient, OBV, SDC, ER and outpatient accounts of discharged and in-house patients (as available) on a daily basis. Follows hospital coding guidelines, UHDDS guidelines, coding rules as established by CMS and reported in Coding Clinics, Medicare, VHQC, American Hospital Association, and American Medical Association (for CPT-4). Complete other duties which include but not limited to the following: Chart review/analysis, filing, record assembly, analysis, and data entry, PI and monitoring activities, completion of admissions, processing 3rd party requests, completion of reports as required by the State Health Department, and answering telephone.
II. Major Responsibilities and Accountabilities
1. Completes coding of ALL in-patient, OBV, SDC, ER and outpatient records on a daily basis utilizing the bill 49 report using the ICD-9-CM, CPT-4 and HCPCS coding books and 3M encoder software to provide accurate codes and DRG assignment.
2. Un-coded charts should be worked on from oldest to newest and high dollar to lower dollar when prioritizing the daily work.
3. Follows hospital coding guidelines, UHDDS guidelines, coding rules as established by CMS and reported in Coding Clinics, Medicare, VHQC, American Hospital Association, and American Medical Association (for CPT-4 and CPT Assistant).
4. "Problem" records are routed to the Health Information Management Director and/or the responsible physician. Whenever necessary, written communication and or queries will be directed to the physician for clarification of coding problems and additional documentation. The documentation and clarification are placed in the permanent medical record.
5. Whenever possible, the records are coded to include a "MCC/CC" and if legal, the sequence may be re-arranged for optimization of DRG reimbursement, but only with the appropriate physician documentation and utilizing approved coding guidelines.
6. Completes ER charge entry process for intravenous infusions, injections and procedures utilizing designated CCS software within four day cut-off timeframe.
7. Follows up on all missing or deficient charts and completes the ER charge entry process for these records.
8. Communicates effectively with departments involved in the charge entry process to ensure accurate patient charging.
9. Monitor and manage the daily Bill 49 report for the coding, abstracting and finalization of all accounts.
10. Completed records are abstracted and billings dropped as soon as possible in order to facilitate quicker turn around time for hospital reimbursement.
11. Reviews and provides feed back to sister facility with our quarterly sister self audit process.
12. Assists with completion of abstracts for Statewide Trauma Registry for patients admitted with trauma. Must follow regulations as specified by State of Virginia . Weekly reports will be run and provided to HIM clerical staff for reporting.
13. Participate in the appeal process for all DRG or coding denials.
14. Answers telephone and responds to requests in a professional, timely manner.
15. Participate in department or hospital wide process improvement committees. Some of which may include the following:
Performance Improvement and monitoring opportunities in the Department
Completion of admission records
Processing 3rd party requests for health information
Reporting of spinal cord/head injuries to the State of Virginia Registry
Chart assembly, analysis, filing consistent with maintaining the UNIT record
Courier duties (delivering and picking up charts, reports, etc.)
III. Hospital Wide Responsibilities/Accountabilities
A. Participates in the Improving Organizational Performance (IOP) process.
B. Performs job duties in a manner that supports THE CORE VALUES, Standards of Behavior and meets performance standards.
C. Meets attendance requirements of absenteeism and lateness.
D. Attends mandatory in-services.
E. Adheres to hospital policies supporting patient rights.
F. Participates in development and attainment of department and/or WCCH Goals.
G. Reports any suspected violations of Corporate Compliance to an immediate supervisor, Corporate Compliance Officer, or the Compliance Hot-Line.
H. Adheres to WCCH policies and procedures regarding privacy and security of health information (HIPAA).
I. Works collaboratively to provide a safe environment for not only the patient, but staff and visitors.
IV. Qualifications (R) = Required (P) = Preferred
A. Education
1. (R) High school diploma or equivalent and Associates of Science in HIM field, and/or RHIT and/or CCS; and, at least three years' acute hospital inpatient, OBV, SDC, ER and outpatient coding experience and practice of medical records
2. (R) Must possess strong communication skills in order to effectively communicate with the Medical Staff
3. (R) Well-versed in medical terminology, anatomy, and physiology, ICD-9-CM and CPT-4 coding guidelines and techniques. Knowledge of DRG's, MS DRGs, PPS, APC's, CMS --Medicare and Medicaid regulations,
B. Experience
(R) 1. 1 to 3 years of acute hospital coding experience
(P) 1. 3 to 5 years of acute hospital coding and extensive MS DRG knowledge
C. Licensures/Certifications
(R) 1. RHIA, RHIT or CCS
V. Physical Demands
The physical demands of this position include; extended periods of sitting and keyboarding. In addition, one must be able to walk, stand, stretch, bend, stoop, and may be required to use the stairs. Hearing acuity and finger dexterity are required for transcription/keyboarding. The employee must be able to speak and communicate clearly. Hand-eye coordination is necessary to operate computers and various pieces of office equipment. One may be required to lift objects suitable for body strength and size up to 50 pounds. This may include above and over-the head lifting during the filing process.
IV. WORKING CONDITIONS
Works in an office environment where there is minimal discomfort due to dust, dirt or excessive noise. Requires the ability to: be mobile, move to all areas of the department and facility, be able to lift objects weighing 10-50 pounds at least, consistent with normal office work using lifting techniques demonstrated/discussed in orientation.
A. Education
1. (R) RHIT and/or CCS; and, at least one year acute hospital inpatient, OBV, SDC, ER and outpatient coding experience and practice of medical records
2. (R) Must possess strong communication skills in order to effectively communicate with the Medical Staff
3. (R) Well-versed in medical terminology, anatomy, and physiology, ICD-9-CM and CPT-4 coding guidelines and techniques. Knowledge of DRG's, MS DRGs, PPS, APC's, CMS --Medicare and Medicaid regulations,
B. Experience
(R) 1. 1 acute hospital coding experience
(P) 1. 1 to 3 years of acute hospital coding and extensive MS DRG knowledge
C. Licensures/Certifications
(R) 1. RHIA, RHIT or CCS