Requires advanced knowledge of and skill in applying International Classification of Diseases and Procedures (ICD), and Current Procedural Terminology (CPT) code sets and associated Medicare/Medicaid rules and guidelines. Reviews and interprets patient medical record documentation to identify pertinent diagnoses and procedures and assigns ICD-10-CM, ICD-10-CM and CPT 4 codes accurately and timely to the highest level of specificity based upon physician documentation for ambulatory surgery, special procedure, observation, emergency department, outpatient ancillary and clinic visit records. Primarily codes complex ambulatory surgery and a mixture of different types of Evaluation & Management medical records. Assists with coding outpatient ancillary clinic, specialty clinic and emergency room record coding as necessary. Communicates with physicians and other providers regarding documentation requirements and collaborates with different departments within CCHCS on patient cases regarding documentation needs and requirements, and coding assignment accuracy. Maintains current knowledge of coding and documentation changes, rules and guidelines.
CCS or CPC with (1) year minimum current and continuous full-time ICD-10-CM & CPT-4 ambulatory surgery and evaluation & management coding.
Knowledge of medical terminology, anatomy and physiology and the disease process.
Ability to work well independently and productively with minimal guidance and supervision.
Detail-oriented, organized and flexible with exceptional interpersonal and communication skills.
Demonstrates coding skills and critical thinking skills utilizing current policies and procedures.
Demonstrated coding knowledge and proficiency is required through on-site evaluation prior to hire.
Knowledge of health insurance processing.
Skilled with electronic medical record applications, automated encoders, and other software applications.
Licensure, Registration, and/or Certification:
Certified Coding Specialist (CCS) required or Certified Professional Coder (CPC) required.
Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred.