Under direct supervision, responsible for the accurate and complete technical coding of Emergency Department (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV) from medical records and edits E & M codes. Working from the appropriate documentation in the medical record, assigns codes and modifiers with ICD-9-CM, CPT, and HCPCS Level II codes where needed. When assigned, review and if necessary correct codes that have been assigned by an Outpatient/Ambulatory coder. This is to ensure that they completed in accordance with the rules, regulations, and coding conventions of ICD-9 CM official guidelines for coding and reporting, Coding Clinic published by the American Hospital Association, the ICD-9-CM code book, CPT, CPT Assistant, CMS, NCCI edits, OSHPD and Kaiser Permanente's organizational/institutional coding guidelines.
Essential Functions:
- Review medical records to identify diagnoses/procedures.
- Under general supervision, organizes and prioritizes all work to ensure that records coded in timeframes will assure compliance with regulatory requirements.
- Demonstrates an in depth, expert level of knowledge of all guidelines concerning the coding and sequencing of diagnoses and procedures as outlined in but not limited to ICD-9-CM, CPT, Uniform Hospital Discharge Data Set (UHDDS), Medicare guidelines and other sources.
- Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding Emergency Department (ED), Hospital Observation (HOPS), and Hospital Ambulatory (HAS), Hospital Outpatient (HOV).
- Acts as a resource person to other hospital departments regarding coding questions and issues.
- Under supervision codes all diagnostic and operative information from the medical record using ICD-9-CM, CPT, and HCPCS coding classification systems.
- Verifies and abstracts all medical data from the record to complete a data abstract on encounters in the following settings: Emergency Department (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV).
- Corrects data as appropriate.
- Ensures that all data abstracted and coded are consistent with ICD-9-CM Official Guidelines for Coding and Reporting, as well as those guidelines outlined by CPT, CPT Assistant, CMS, UHDDS, JCAHO, NCQA, OSHPD, and KP regional and local policies.
- Participates in quality improvement for coding, abstracting, and/or APC assignments.
- Under general supervision, interacts with physicians to clarify and promote accurate documentation of patient diagnostic and procedural information.
- Enters patient information into the computerized outpatient medical record databases, ensuring accuracy and integrity of the medical record abstract or encounter data prior to transmitting case.
- Ensures timely record completion by meeting coding and abstracting productivity/quality standards.
- Participates in medical record documentation auditing to monitor physician compliance with regulatory requirements i.e. Physical Review Project in concert with appropriate managers.
- May provide physician review and education based on review findings.
- The above duty statements intend to describe the general nature and level of work performed by individuals assigned to positions in this classification and, as such, construes as an exhaustive list of duties, responsibilities and skills required of every position so classified.
- Perform other duties as assigned.
- No supervisory responsibilities.
Qualifications:
Basic Qualifications:
- Must have completed an AHIMA accredited coding program OR have a minimum one (1) year of continuous coding/abstracting experience within the last five (5) years AND possess the appropriate credentialed referenced above.
- High school diploma or GED.
- Completion of classes in medical terminology, anatomy, and physiology.
- Current ICD-CM, ICD-PCS and CPT coding conventions and disease process from an accredited program is required.
- This position requires a CCA, CCS, RHIT or RHIA.
- A passing score of 75% on the Kaiser Permanente coding test for an Outpatient/Ambulatory Coder. Successfully passing the coding test is required regardless of experience.
- Must maintain a minimum of ten (10) CE hours annually.
- Must maintain current coding credential.
- Demonstrated knowledge of anatomy and physiology, medical terminology, disease processes, basic knowledge of reimbursement methodologies (DRGs, APCs) and conventions, rules, guidelines for current coding classifications (ICD-9-CM, ICD-PCS, CPT, HCPCS Level II).
- Demonstrated ability to understand the clinical contents of a health record.
- Demonstrated ability to communicate with physicians in order to clarify diagnoses/procedures and properly sequence them for coding.
- Must be able to meet quantity and quality standards.
- Will abide by the AHIMA coding code of ethics.
Skills Testing: Outpatient/Ambulatory Coder Test(passing score of 75% or more)
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.