Under general supervision, is responsible for accurate coding of all inpatient & outpatient services, procedures, diagnoses & conditions, working from the appropriate documentation in the medical record. Classification systems include ICD-9-CM & CPT as well as other specialty systems as required by diagnostic category. All work is carried out in accordance w/ the rules, regulations & coding conventions of the American Hospital Association (Coding Clinic), ICD9, OSHPD, & KP Coding Guidelines.
Verifies/corrects abstracted demographic & clinical data. As needed, Coder II's may be required to assist & be a resource for data integrity & the work of Coders I and/or other employees in the Health Information Management Department who need instruction & assistance in coding e.g., defining charts by diagnoses or procedures. May also be required to provide professional guidance, advice & instruction to Coders I.
Essential Functions:
- Upholds KP's Policies & Procedures, Principles of Responsibilities & applicable state, federal & local laws
- Maintains timely coding & abstracting productivity & quality standards
- Review medical records to identify diagnoses/procedures
- Independently organizes & prioritizes all work to ensure that records are coded in time frames that will assure compliance w/ regulatory requirements
- Demonstrates a comprehensive knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM, Uniform Hospital Discharge Data Set & Medicare Guidelines
- Demonstrates knowledge of Anatomy & Physiology to interpret general medical classifications for coding discharge data including the most complicated encounters/cases
- Assigns Codes
- Codes all diagnostic & operative information from the medical record using ICD-9-CM & CPT coding classification systems & independently quality checks own work
- Selects the DRG for each inpatient case
- Optimizes hospital payment legitimately & ethically by utilizing approved coding guidelines & conventions
- Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment
- Verifies & abstracts, all medical data from the record to complete a data abstract on each hospital encounter
- Corrects data as appropriate
- Ensures that all data abstracted is consistent w/ guidelines outlined by JCAHO, OSHPD & regional & local policies
- Completion of Medical Records
- Interacts w/ physicians to clarify & accurately document patient diagnostic & procedural information through a query process
- Enters patient information into the computerized inpatient & outpatient medical record databases, ensuring the accuracy & integrity of the medical record abstract data prior to transmitting case to Government Reimbursement for billing
- Ensures timely record availability by meeting established coding & abstracting productivity standards
- Independently conducts medical record documentation auditing to monitor physician compliance w/ regulatory requirements i.e., Physician Review Project
- Confidentiality/Security of Systems
- Maintains & complies w/ policies & procedures for confidentiality of all patient records
- Demonstrates knowledge of security of systems by not sharing computer logons
- Other Duties
- Answers the telephone promptly & identifies themselves & the department
- Trains & instructs employees as appropriate
- Acts as an expert resource person to other coders & personnel in other hospital departments regarding coding questions & issues
- May perform other duties as assigned by supervisors
Qualifications:
Pay Grade: 15
Basic Qualifications:
- Requires one (1) of the following current credentials: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder-Hospital (CPC-H) or Certified Coding Specialist (CCS).
- Completion of classes in Medical Terminology, Anatomy/ Physiology, ICD-9 and CPT coding conventions conforming to standards established by the American Hospital Association (Coding Clinic), American Medical Association, CMS or successful completion of an AAPC or AHIMA accredited coding certification program.
- Obtain a passing score on a KP HIM Coder II coding Assessment.
- Keyboarding skills.
External hires must pass a background check/drug screen.
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