• Coder Level IV

    ID
    2018-22514
    Department
    Health Information Management
    Work Hours
    0730-1600
    Position Type
    Regular Full-Time
    Hours Per 2-Week Pay Period
    80 Hours
    Location
    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, a Coder Level IV is primarily responsible for coding and abstracting all inpatient discharges.  During periods of staffing shortages or backlog in areas other than inpatient coding, a Coder Level IV may be assigned any of the following areas of outpatient coding by the Manager, HIM (Coding): Cardiovascular/Invasive Radiology Ambulatory  Surgery/Procedure, non-cardiovascular/interventional radiology Ambulatory Surgery/Procedure, Observation (both Cardiovascular/Invasive Radiology and Medical), Emergency Care Center/Fast Track (technical and/or professional components), Ancillary/Clinic/OB-GYN/Medical Necessity or SNF accounts.

    Responsibilities

    GENERAL CODING REQUIREMENTS

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

    INPATIENT RECORDS

    1. Accurately assigns and abstracts ICD-9 CM codes for principle diagnosis and/or principle procedure to inpatient accounts to ensure proper DRG reimbursement
    2. Accurately assigns and abstracts ICD-9 CM secondary diagnosis/procedure codes as appropriate.
    3. Assures the most appropriate MS-DRG or APR-DRG is assigned to inpatient accounts.
    4. Accurately assigns and abstracts Present on Admission indicators, Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, type of anesthesia, and tissue specimen information as appropriate for inpatient accounts.

    CARDIOVASCULAR/INTERVENTIONAL RADIOLOGY/VASCULAR OBSERVATION RECORDS

    1. Accurately assigns and abstracts ICD-9-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/ SURGICAL OBSERVATION RECORDS (NOT CARDIOVASCULAR / INTERVENTIONAL RADIOLOGY/VASCULAR)

    1. Accurately assigns and abstracts ICD-9-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).

    GENERAL AMBULATORY SURGERY/PROCEDURE RECORDS

    (NOT CARDIOVASCULAR/INVASIVE RADIOLOGY/VASCULAR)

    1. Accurately assigns and abstracts ICD-9-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 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-9-CM diagnostic and CPT procedure and Evaluation and Management codes for facility services.
    2. Accurately assigns and abstracts ICD-9-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-9-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-9-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-9CM and CPT coding guidelines and conventions.
    4. Understanding of Medical Necessity for Medicare targeted tests.
    5. CCS, CCS-P, RHIT or RHIA credential.
    6. A minimum of one year of experience coding inpatient accounts in an acute care setting; PLUS

      A minimum of three years experience coding Cardiovascular/Interventional Radiology/Vascular  Ambulatory Surgery/Procedure/Observation, Medical or General Surgery Observation, General Ambulatory Surgery/Procedure (not cardiovascular/interventional radiology/vascular), Emergency Care Center/Fast Track (technical and professional components), Ancillary Services, Clinics, OB-GYN, Medical Necessity and SNF accounts.
    7. Ability to achieve and maintain a 93% accuracy level while meeting AHIMA productivity benchmarks for assigned primary coding duties.
    8. Other duties as assigned by the Coding Manager.

    9. Work requires a high degree of interpersonal skills to interact with the Medical Staff, co-workers and staff from other departments.

    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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