Coder Level III

ID
2017-21274
Department
Health Information Management
Work Hours
Flexible
Position Type
Regular Full-Time
Hours Per 2-Week Pay Period
80 Hours
US-NY-Plattsburgh
Weekend Requirements
Weekends and holidays as scheduled

Overview

Under the general supervision of the Manager, HIM (Coding) and following established hospital and Department policies and procedures, the Coder III will apply ICD-10 CM diagnostic and procedure codes as well as CPT procedure and/or Evaluation and Management codes to non-cardiovascular/interventional radiology Ambulatory Surgery/Procedure, Medical and Non-cardiovascular/interventional Observation, Emergency Care Center /Fast Track (technical and professional), Ancillary Services/Clinics/OB-GYN/Medical Necessity and SNF accounts as appropriate.

Special Criteria Details

Remote Coding Position

Responsibilities

GENERAL CODING REQUIREMENTS

  1. Understands the principles of, and is able to assign, ICD-10CM diagnostic and procedural codes.
  2. Understands the principles of, and is able to assign, CPT-4 procedure and Evaluation and Management codes.
  3. Has a good working knowledge of Medical Terminology.
  4. Has a good working knowledge of Anatomy and Physiology.
  5. Ability to use online encoder, clinical abstracting system, HIM operating system, clinical and financial systems as needed.
  6. Maintains a working knowledge of governmental regulations, protocols and third party requirements regarding billing and billing documentation
  7. Understands and is able to apply CMS documentation and coding guidelines specific to outpatient observation accounts.
  8. Maintains an accuracy level of at least 93% for assigned primary coding duties.
  9. Maintains AHIMA productivity benchmarks for assigned primary coding duties.
  10. Completes AHIMA or AAPC CE requirements for credential.
  11. Maintains good rapport with the Medical and HIM Department staff.
  12. Maintains use of space, materials, supplies, and equipment. Requests repair and replacement as required.
  13. Performs all other duties as assigned.

GENERAL AMBULATORY SURGERY/PROCEDURE RECORDS

(NOT CARDIOVASCULAR/INVASIVE RADIOLOGY/VASCULAR)

  1. Accurately assigns and abstracts ICD-10-CM diagnostic and CPT procedure codes.
  2. Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen Information for outpatient records.
  3. Routes records to the appropriate area (i.e., logging, re-logging, data entry, recheck, or complete file).

CARDIOVASCULAR/INTERVENTIONAL RADIOLOGY/VASCULAR OBSERVATION RECORDS

  1. Accurately assigns and abstracts ICD-10-CM diagnostic and CPT procedure codes for types of outpatient cardiology /interventional radiology/vascular procedures.
  2. Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen information as appropriate for outpatient records.
  3. Routes records to the appropriate area (i.e., logging, re-logging, data entry, recheck, or complete file).

MEDICAL OR GENERAL SURGERY / PROCEDURE OBSERVATION RECORDS (NOT CARDIOVASCULAR / INTERVENTIONAL RADIOLOGY OBSERVATION RECORDS)

  1. Accurately assigns and abstracts ICD-10-CM diagnostic and CPT procedure codes as appropriate
  2. Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen information as appropriate for outpatient accounts.
  3. Routes records to the appropriate area (i.e., logging, re-logging, data entry, recheck, or complete file).

EMERGENCY CARE CENTER / FAST TRACK RECORDS

  1. Accurately assigns and abstracts ICD-10-CM diagnostic and CPT procedure and Evaluation and Management codes for facility services.
  2. Accurately assigns and abstracts ICD-10-CM diagnostic and CPT procedure and Evaluation and Management codes for professional services.
  3. Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen information as appropriate for Emergency Care Center / Fast Track accounts.

ANCILLARY SERVICES/CLINICS/OB-GYN/MEDICAL NECESSIRY

  1. Accurately assigns and abstracts ICD-10-CM diagnostic and CPT procedure codes as appropriate.
  2. Performs Medical Necessity review and follow-up per ICD-9CM coding guidelines and conventions and HIM Coding Department policy/procedure..

SKILLED NURSING UNIT RECORDS

  1. Accurately assigns and abstracts ICD-10-CM diagnostic and procedure codes for CVPH SNF patient accounts.
  2. Regularly reviews SNF in-house records and codes additional diagnoses as needed.

Qualifications

  1. High School Diploma required.
  2. Successful completion of medical terminology, anatomy and physiology classes.
  3. Working knowledge of ICD-10CM and CPT coding guidelines and conventions.
  4. Understanding of Medical Necessity for Medicare targeted tests.
  5. A minimum of one year experience coding non-cardiovascular ambulatory surgeries/procedures (i.e. orthopedic, podiatric, gastrointestinal, OB-GYN, etc.) and Medical or General Surgery Observation accounts. Plus a minimum of two years experience coding Emergency Care Center/Fast Track, Ancillary Services, Clinics, OB-GYN, Medical Necessity and SNF accounts.

                                                            -OR-

A minimum of one year experience coding non-cardiovascular ambulatory surgeries/procedures (i.e. orthopedic, podiatric, gastrointestinal, OB-GYN, etc.) and Medical or General Surgery Observation accounts – and - CCS, CCS-P, RHIT, RHIA, or CPC credential.

  1. Experience in outpatient Cardiovascular/Invasive Radiology coding preferred.
  2. CCS, CCS-P, RHIT, RHIA, or CPC credential required.
  3. Work requires a moderate level of interpersonal skills to interact with the Medical Staff, co-workers, and staff from various departments.
  4. Ability to achieve and maintain at least a 93% accuracy level while meeting AHIMA productivity benchmarks for assigned primary coding duties
  5. Work requires a moderate level of interpersonal skills to interact with the Medical Staff, co-workers, and staff from various departments.
  6. Other duties as assigned by the Coding Manager or HIM Director.

As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.

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