Employment Type:

Full time

Shift:

Description:

POSITION PURPOSE

Analyzes physician/provider documentation contained in assigned Emergency Department (ED) and Outpatient Observation health records (electronic, paper or hybrid) to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Accesses charge work queues and systems to assign ER and Observation charges if performed by HIM. May also require calculation of Observation hours if performed by HIM.

Utilizes encoder software applications, which includes all applicable online tools and references in the assignment of Internal Classification of Diseases, Clinical Modification diagnosis and procedure codes, and Current Procedural Terminology / Healthcare Common Procedure Coding System (HCPCS) procedure codes and all required modifiers.

Utilizes coding guidelines established by:

• The Centers for Medicare/Medicaid Services (CMS) ICD-CM Official Coding Guidelines for Coding and Reporting, ICD-PCS Official Guidelines for Coding and Reporting
• The American Hospital Association (AHA) Coding Clinic
• The American Medical Association (AMA) for CPT codes and CPT Assistant
• The American Health Information Management Association (AHIMA) Standards of Ethical Coding
• Revenue Excellence/Health Ministry (HM) coding procedures and guidelines

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.   

Navigates the patient health record and other computer systems/sources in determination of diagnoses, reason for visit, procedures and modifiers to be coded and/or for APC assignment.

Codes Emergency Department and Outpatient Observation records utilizing encoder software and online tools and references, in the assignment of ICD, CPT, and HCPCS codes and modifiers. 

Accesses charge work queues, systems to assign ER and Observation charges and hours, based on medical record documentation, if performed by HIM at a Health Ministry.  

Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous documentation.  

Communicates effectively with clinical staff, physicians and office staff regarding documentation issues or needs. Communicates with case management concerning Outpatient Observation documentation issues. 

Works with HIM and Patient Business Services (PBS) teams, when needed, to help resolve billing, claims, denials and appeals issues affecting reimbursement.

Exhibits awareness of health record documentation or other coding ethics concerns. Notifies appropriate leadership for assistance, resolution when appropriate.

Utilizes EMR communication tools to track missing documentation or Outpatient queries that require follow-up to facilitate coding in a timely fashion.

Maintains current knowledge of changes in Outpatient coding and reimbursement guidelines and regulations e.g., new modifiers.  

Consistently meets or exceeds coding quality and productivity standards established by Revenue Excellence/HM.

Maintains CEUs as appropriate for coding credentials as required by credentialing associations.

Performs other duties as assigned by leadership.

Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

MINIMUM QUALIFICATIONS

Completion of an AHIMA-approved coding program or an AAPC-approved coding program, or Associate’s degree in Health Information Technology or a related field or an equivalent combination of years of education and experience is required. Bachelor’s degree in Health Information Management (HIM) or related healthcare field is preferred. 

Certified Coding Associate (CCA), Certified Procedural Coder Apprentice (CPCA), Certified Procedural Coder (CPC), Certified Outpatient Coder (COC), Registered Health Information Technician (RHIT),  Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) is required.

Two (2) years of current acute care coding emergency department and observation or physician coding experience is required. 

Current experience utilizing encoding/grouping software or CAC is preferred.