Description This position's primary purpose is to accurately abstract, code, and electronically record all diagnoses and procedures documented by a physician in any non-surgical outpatient medical record (i.e. Emergency Department visits, outpatient diagnostic ancillary visits) In accordance with current Federal Coding Compliance regulations and guidelines, and using current ICD-10-CM , CPT-4, and HCPCS code sets/systems.
Core Competencies- Reviews the assignment and sequencing of codes for
the principal procedure, other significant invasive and non-invasive procedures according to the coding conventions and guidelines outlined in the CPT code set, the National Correct Coding Initiative (NCCI), the Outpatient Coding Editor (OCE), and the AMA CPT Assistant publication. - Reviews the assignment and sequencing of codes for the principal diagnosis, principal procedure, complications and comorbid (CC) conditions, and other significant invasive and non-invasive procedures that should be coded according to ICD-10-CM official guidelines for coding and reporting, published by the U.S. Department of Health and Human Services (DHHS) and the AHA Coding Clinic for ICD-10-CM.
- Applies Medicare Outpatient Prospective Payment System (OPPS) coding assignment requirements regarding the following: Modifiers approved for Hospital Outpatient use, CPT consistent with HCPCS Level II , Medical Necessity Justification (i.e., linking diagnosis to procedure/service performed), Evaluation and Management code assignment, when necessary.
- Consults with physicians and other healthcare providers to obtain clarification documentation to assist with accurate and complete diagnosis and procedure code assignments.
- Demonstrates competency in performance of coding functions by maintaining current knowledge in ICD-10-CM, CPT, and HCPCS coding.
- Assists with the accurate abstraction and the correction of 'hospital discharge data set' through the Medical Information Reporting for California (MIRCal) system, in accordance with the regulations administered by the Office of Statewide Health, Planning nd Development (OSHPD).
- Maintains a daily productivity level according to the benchmarks and standards outline in the HIM department policy and procedure.
Department Specific Competencies- Participates in departmental and hospital performance improvement activities (BPI projects, task forces, etc) when appropriate.
- Answers telephone in a timely manner and ascertains needs and routes accordingly.
- Performs clerical tasks and other duties as assigned.
EducationDegreeProgramCertificateHealthcareN/AHealthcare
Additional InformationHigh School Diploma, GED, or Higher Education. Completion of an 'American Health Information Management Association' (AHIMA) or an 'American Academy of Professional Coders' (AAPC) approved/sanctioned ICD-10-CM & CPT-4 coding certification program. Completion of (1) Medical Terminology and (2) Anatomy & Physiology courses. One of the following certifications is required: AHIMA CCS; AHIMA CCA; AHIMA CCS-P; AAPC Certified Professional Coder - Hospital CPC-H
ExperienceNumber of Years ExperienceType of Experience3ancillary and/or emergency department coding experience
Additional InformationN/A
License / Certification RequirementsCompensation Range: $32.72 - 51.47 / Hour
