Coding Specialist

Summary:
The Coding Specialist reports to the Coding Manager or designee. Under the general supervision and within Lifespan and department policies and procedures reviews the medical record assigning the appropriate ICD-9-CM and/or CPT procedure code. Examine the medical record to ensure the documentation supports the code assignment. Queries the physician when documentation in the record is inadequate ambiguous or unclear for coding purposes.

 

Responsibilities:
Reads the medical record identifying all treated diagnoses and procedures reporting the correct code(s) adhering to rules set forth in “Official Coding Guidelines.” Ensures the medical record documentation supports the codes selected for the principal diagnosis secondary diagnoses complications co-morbid conditions procedures and discharge disposition. Abides by the “Standards of Ethical Coding” as set forth by the American Health Information Management Association. Understands clinical documentation to recognize when a query to the physician is necessary.



Enters coded/abstracted information into the 3M MS DRG or APR DRG grouper assigning the accurate MS DRG or APR DRG through use of the clinical analyzing functions reviewed in compliance with medical record documentation. Adds Present On Admission (POA) indicator to diagnoses. Selects the physician performing procedures ensuring accuracy in the hospital’s billing system. Updates Clinical Documentation monitor. Sends inpatient accounts to the coding validation software program upon which validator reviews selected cases.



Follows-up on all bills holds to ensure timely billing and reimbursement.



Refers coding billing and system questions to the coding manager or coding validator. Seeks supervisory assistance only after exhausting own resources by referencing appropriate coding publications and manuals.



Keeps abreast of coding guidelines and reimbursement reporting requirements.



Maintains health information confidentiality by adhering to established organizational and departmental policies and procedures.



Performs related clerical and other duties as assigned.

 

Other information:
BASIC KNOWLEDGE:

Associate degree in health information technology or related field with successful completion of formal education in coding such as a Coding Certificate Program or in process of obtaining coding education.



Coding certification required and/or coding certification obtained within one-year of hire date from AHIMA (American Health Information Management) or AAPC (American Academy of Professional Coders.)



EXPERIENCE:

Six months experience working in an office setting preferably with medical records and/or formal education in medical terminology anatomy and other coding-related course.



Familiarity and understanding of the content of the medical record.



Trained in anatomy physiology and disease processes and/or in process of attainment.



Ability to recognize and understand clinical documentation pertinent for coding.



Good writing skills to prepare physician queries.



Computer skills to research internet websites to clarify diseases or procedures.



Ability to access and recognize appropriate electronic documents for coding.



WORKING CONDITIONS:

Reads medical records for the entire workday.



Ability to lift a minimum of 25 pounds bend stoop stretch use step-stools to file records.



Ability to work under stressful conditions to maintain accounts receivable days achieving productivity and accuracy.



SUPERVISORY RESPONSIBILITY: None



 

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Lifespan is a VEVRAA Federal Contractor.

 

Location: Rhode Island Hospital USA:RI:Providence

 

Work Type: Full Time

 

Shift: 4

 

Union: Non-Union