POSITION SUMMARY: 

Under the direction of the Health Information Management Director, the Outpatient Coder I accurately determines ICD-10-CM diagnosis, and ICD-10-CM, CPT and HCPCS  procedure codes for all outpatient medical records that could include Emergency Department (ED), outpatient laboratory, diagnostic imaging, minor outpatient procedures, infusion and injections, outpatient labor and delivery, recurring accounts and observation stays.

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POSITION RESPONSIBILITIES:

• Abstract pertinent information from patient records within various outpatient types.  Assign International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) / International Classification of Diseases, Tenth Revision, Clinical Modification Procedural Coding System (ICD-10 PCS) codes or Healthcare Current Procedural Coding System (HCPCS) codes, creating ambulatory payment classification (APC).
• Monitor and manage the discharged not final billed (DNFB) accounts within assigned patient types daily to meet financial goals and expectations. 
• Meet coding productivity standards and accuracy rate determined by company policy. (See Coding Productivity and Quality Standards.)
• Queries clinical staff to achieve accuracy in coding
• Educate, train and communicate with medical staff regarding accurate documentation for the purposes of coding. 
• Keep abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.  Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Abstracts data and reports to the Virginia Trauma Registry.
• Participate in the appeals process for coding denials.  Initiate and respond to requests for billing to support medical necessity, appropriateness of code assignment, combining accounts based on payer requirements and other activities to support the billing function.
• Answer telephone and respond to requests in a professional, timely manner.
• Maintain professional credentials through ongoing coding education as well as company requirements for annual continuing education.
• Contributes to quality improvement activities of the department and the organization, including participating in internal department and corporate audits.
• Participates in other department or organizational activities as requested.

 

KNOWLEDGE, SKILLS and ABILITIES:

1. Effective Oral and written communication skills
2. Demonstrated competence with personal computers, networks, and Microsoft Office.
3. Experience with various abstracting and coding systems and electronic health record systems.
4. Ability to work independently or as a team member to accomplish tasks or projects
5. Ability to prioritize work assignments during periods of stress
6. Ability to sit for long periods of time
7. Corrected visual acuity for long periods of reviewing/reading medical records and viewing a computer monitor
8. Knowledge and skills to correctly assign reason for visit/first listed diagnosis for outpatient encounters.  Correctly assign additional diagnoses based on coding rules and guidelines
9. Critical thinking, time management, and organizational skills

 

 

AGES OF POPULATION SERVED:

Age Specific	Definition	Yes	No
Birth to One Year	Infant
2 – 3 Years	Toddler
4 - 5 Years	Pre-Schooler
6 – 11 years	School Age
12 - 17 years	Adolescent
18 – 30 years	Young Adult
31 – 64 years	Adult
65+	Geriatric
No responsibility to treat or care for patients		X

 

WORKING CONDITIONS:

Exposure to:	None	Some	Frequent
Toxic/caustic chemicals	X
Working outdoors	X
Dust/fumes/gases/helicopter	X
Moving mechanical parts	X
Blood or Body Fluids	X
Communicable Diseases	X
Potential electrical shock	X
X-ray electromagnetic energy	X
Needles or sharp objects	X
Frequent repetitive motions		X
Use/viewing of Computer monitor			X
Unprotected heights	X
Physically or verbally abusive patients	X
Hazards in patients’ homes	X
Extreme heat or cold	X
50% of time spent traveling	X
Exposure to high pitched noises	X
Blood born pathogen exposure	X
Stressful Environment		X

 

PHYSICAL DEMANDS/LIFTING REQUIREMENTS:

( X )     Sedentary Work:  Lifting 10 lbs. maximum and occasionally lifting and/or carrying articles.

(  )        Light Work:  Lifting 2 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs.

(  )        Medium Work:  Lifting 50 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs.

( )         Heavy Work:  Lifting 100 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 50 lbs.

(  )        Very Heavy Work:  Lifting objects in excess of 100 lbs. with frequent lifting and/or carrying of objects weighing 50 lbs. or more.

( )         Ability to lift, push and pull with assistance of mechanical device or co-worker

Activity	Some	Frequent
Repeated Bending, Stooping, Kneeling, Crouching	X
Working in confined area	X
Ability to distinguish Colors	X
Standing/Walking > 25%	X
Standing/Walking > 50%
Standing/Walking > 75%
Manual hand/finger dexterity		X
Multi-tasking, ability to work with frequent interruptions	X
Hand/eye coordination	X
Sitting > 50%	X
Use of Computer >75%	X
Critical Thinking Skills	X
Reaching above shoulder level	X
Climbing on Ladder
Operating Motor Vehicle or motorized equipment

 

POSITION REQUIREMENTS:  

1. Post high school specialty or vocational training with a specialization in courses in medical terminology, anatomy and physiology, basic disease process, ICD-10-CM and CPT-4 or equivalent competency
2. Successful completion of a coding certificate program in a program with American Health Information Management Association approval status
3. Minimum of 1 year of acute hospital coding and abstracting experience required
4. Experience and/or education in ICD-10 CM/ ICD-10 Procedural Coding System (PCS) coding required
5. Certification or licensure as a:
   1. Certified Coding Specialist (CCS) or must obtain CCS credential within 2 years (required)

or

1. Registered Health Information Administrator (RHIA) or
2. Registered Health Information Technician (RHIT) or
3. Certified Professional Coder-Hospital (CPC-H)

And must obtain the CCS credential within 2 years of employment or have equivalent acute care coding and abstracting experience.