Coder Level II

Under the general supervision of the Manager, HIM (Coding) and following established hospital and Department policies and procedures, a Coder Level II will apply ICD-10 CM diagnostic and procedure codes as well as CPT procedure and Evaluation and Management codes to outpatient Emergency Care Center/Fast Track accounts. A Coder Level II will also be proficient in at least one other area of outpatient coding (ex. Ancillary Services, Clinics, OB-GYN, Medical Necessity, SNF).

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, MIS 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. Maintains an accuracy level of at least 93% for assigned primary coding duties.
8. Maintains AHIMA productivity benchmarks for assigned primary coding duties.
9. Completes AHIMA CE requirements for credential
10. Maintains good rapport with the Medical and HIM Department staff.
11. Maintains use of space, materials, supplies, and equipment. Requests repair and replacement as required.
12. Performs all other duties as assigned.

EMERGENCY CARE CENTER/FAST TRACK RECORDED

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 abstracts 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 NECESSITY

1. Accurately assigns and abstracts appropriate ICD-10-CM diagnostic and CPT procedure codes for Ancillary Services/Clinics/OB-GYN/Medical Necessity accounts.
2. Performs Medical Necessity review and follow-up per ICD-10 CM coding guidelines and conventions and MIS Coding policy and 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.

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. One of the following experience/credential options:

• A minimum of two years experience in Emergency Department (technical and profession).
• A minimum of one year experience in Emergency Department (technical and professional) coding –PLUS- a   minimum of one year experience in Ancillary Services/Clinic/OB-GYN/Medical Necessity/SNF coding and CCS, CCS-P, RHIT, or RHIA credential.

1. Ability to achieve and maintain at least a 93% accuracy level while meeting AHIMA productivity benchmarks for assigned primary coding duties.
2. Work requires a moderate level of interpersonal skills to interact with the Medical Staff, co-workers, and staff from various departments.
3. If the candidate is already in a Coder Level I position and wishes to train up to a Coder Level II position they will be eligible for Coder Level II pay rate once they are released from training on Emergency Department coding (technical and professional).

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.