Job Description

Position Summary:
-Reviews clinical documentation and diagnostic results and applies appropriate ICD-10-CM, and CPT-4 codes.
-Codes are used for billing, internal and external reporting, research and regulatory compliance activities.
-Resolves billing related errors and assists with workflow changes and process improvement projects.
-Meets ongoing productivity and quality standard of 95% accuracy rate or better.
-Verifies that all ICD-10 codes are correctly captured.
-Verifies that physician is correctly abstracted.
-Keeps abreast of coding guideline changes.
-May identify chargeable items for facility level for given department.
-May assign codes for diagnoses and treatment for ancillary outpatient encounters.
-Abides by the standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to all official coding guidelines.
-Performs other duties as assigned.
-Additionally, the Coder III utilize0s technical coding principles and APC reimbursement expertise to assign appropriate ICD-10-CM and CPt-4 procedures.
-Assigns codes for diagnoses, treatment and procedure for multiple specialized departments, including Outpatient ancillary, Emergency Department, and Inpatient and Outpatient Surgery.
-Determines the correct principal diagnosis, co-morbidities, complications, secondary conditions and surgical procedures.
-Assigns MS-DRG, Present on Admission (POA) indicators, Hospital Acquired conditions), and accurately abstracts discharge dispositions.
-Queries physicians per established policy and procedure when documentation is not clear or conflicting.

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