Medical Coder

Overview:

The coding function is a primary source for data and information used in health care and promotes provider/patient continuity, accurate database information, and the ability for SWH clients to receive appropriate reimbursement. The coding function also ensures compliance with established coding guidelines, third-party reimbursement policies, regulations and accreditation guidelines.

The Shearwater Health (SWH) Medical Coder performs technical and specialized data analytic functions for SWH's acute care hospitals and for other clients including those who manage payment policy for payers. The employee abstracts clinical information from health records and assigns accurate and complete ICD-10-CM, CPT-4 codes and other medical codes and DRG Assignments as needed in accordance with Official Coding Guidelines and SWH client guidelines as appropriate. The employee reviews facility health records for accuracy and completeness of coding and DRG assignment. On occasion, the employee may code for purposes other than traditional patient billing and provide services in support of coding such as coding and payment policy research.

PRIMARY DUTIES:

• Responsible for assessing and determining the accuracy of all ICD-10-CM, HCPCS, and CPT code assignments for RAC review.
• Reviews and resolve claim edit, denials, and appeals for ED Visit specifically Medicare Part A and B coverage.
• Participated in continuing education classes to ensure ICD-10-CM, HCPCS, and CPS guidelines are up-to-date.
• Develop and coordinate educational and training programs regarding elements of coding such as appropriate documentation, appropriate coding, error trends found during chart review, third party audit findings, and annual coding updates.
• Ability to initiate prompt responses and appropriate corrective action.
• Reviews and resolve claim edit, denials, and appeals for ED Visit specifically Medicare Part A and B coverage.
• Determines the adequacy of physician documentation to support the codes assigned.
• Abide by the Standards of Ethical Coding, set forth by the American Health Information Management Association (AHIMA), adhere to official coding guidelines, and maintain current knowledge of the information contained in the Coding Clinic, CPT Assistant, and the Official Guidelines for Coding and Reporting.
• Knowledge, understanding, and compliance with all applicable Federal and Local laws and regulatory statutes relating to coding and documentation.

ESSENTIAL FUNCTIONS (time allocations estimated)

• Uses telephone on an average of 3% of the workday in normal communication with clients and supervisors.
• Communicates verbally on an average of 3% of the workday with clients, peers and supervisor.
• Uses reading skills and another visual acuity on an average of 95% of the workday to abstract, code and review written and electronic documents.
• Works on a personal computer or other CRT/workstation on an average of 95% of the workday to input, maintain and manipulate pertinent data.
• Works on other office equipment (printer/copier; fax; shredder) on an average of 1% of the workday.
• Uses writing skills on an average of 20% of the workday to develop correspondence, activity reports and other written documents.
• In all activities, uses analytical, judgment, and decision-making skills in meeting the objectives of the position.

EDUCATION AND EXPERIENCE:

SWH requires a BS in Nursing and PRC licensed, ideally in a clinical area of practice and/or previous experience as a medical coder. Previous coding experience will ideally consist of two (2) years of coding experience using ICD-10-CM or equivalency with a focus on inpatient coding. The employee must have an excellent command of medical terminology, anatomy and physiology, and United States health record content. Fluency coding in multiple types of records: inpatient, outpatient (ER, diagnostic, injections/infusions or observation) and ambulatory surgery is desired at the time of hire or will be required after completion of training. Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or other AHIMA or AAPC approved coding credential is desired within six months of hire. The employee is expected to enroll in continuing education courses to maintain certification as approved by SWH.

COMPLEXITY OF DUTIES:

Duties are highly complex, varied, require planning and coordinating several activities at one time, and demand the use of problem-solving skills and analysis of circumstances to develop appropriate actions.

RESPONSIBILITY FOR ACCURACY:

Review of work and subsequent procedures will detect the most significant errors of job functions. However, more serious errors could result in inefficient operations and loss of revenue. Because the information in the health record is the basis for reimbursement as well as clinical decision-making, coding entries must be complete and accurate. The amount of reimbursement depends on the correct coding of diagnoses and procedures and appropriate DRG/APC assignment. The work has a direct effect on medical record keeping and a direct impact on the accuracy, documentation, timeliness, reliability and acceptability of information in the medical record services. SWH expects all Medical Coders to meet or exceed 95% accuracy as measured by externally engaged quality assurance coding companies.

MENTAL/VISUAL/PHYSICAL EFFORT:

High levels of mental concentration are required. Must handle multiple tasks simultaneously and is subject to interruptions. The physical effort requires sitting and reaching with hands and arms. Manual dexterity, visual acuity, and the ability to communicate in English are required. Work is performed in a normal business office environment, most often on the night shift however some work may be scheduled during the daytime.

PRODUCTION REQUIREMENTS

While inpatient coding is the primary focus of the position, other coding assignments will develop from time to time. SWH expects competent inpatient coders to produce no less than three (3) charts per hour at a 96% or higher accuracy rate as measured bases on quality assurance audits. Coders scoring under 96% accuracy will be placed on a performance improvement plan and failure to improve may be grounds for dismissal.