ED Clinical Coding Specialist Certified

POSITION SUMMARY

The responsibility of the ED/Clinic Coding Specialist is to search a patient’s entire medical record to ensure comprehensive coding and abstracting utilizing the coding rules, principles and ethics under the supervision of the Coding Supervisor and Manager, Health Information Management.  With reimbursement contingent upon coding, it is the responsibility of the ED/Clinic Coding Specialist to have knowledge of ICD-10, CPT-4 and APC coding rules and principles.  Review all claims for accurate departmental charges before billing and to make medical determinations.  Contact physician’s offices by telephone or fax for diagnosis.  

MINIMUM REQUIREMENTS

Education:

1. Graduate of an approved Health Information Management Technology program, preferred, with Registered Health Information Technician (RHIT) credentials, Certified Coding Specialist (CCS), or Certified Professional Coder (CPC) or other relevant credential, relevant experience, required or eligible.  
2. As a secondary preference will also consider graduates of Medical Secretarial program with current, acute care experience with ICD-10-, CPT, DRG, and APC coding rules and methodologies with Certified Coding Specialists (CCS) credential or other relevant credential, relevant experience, required or eligible. 

Experience:

1. No previous work experience is required.  
2. Current, acute care experience with ICD-10, CPT, DRG, APC coding rules and methodologies preferred.

Knowledge, Skills, Abilities:

1. Demonstrates knowledge of diagnostic and procedural terminology, medical terminology and disease processes (anatomy and physiology).
2. Self-motivated individual with personal integrity to organize work and work independently.
3. Possesses typing skills with basic knowledge of computer operations.
4. Demonstrates communication skills necessary to approach the medical staff, hospital personnel, ancillary department etc. for any clarifications regarding record questions or problems utilizing coding rules and principles.

License/Certification/Registration:

1. Registered Health Information Technician (RHIT) credentials, Certified Coding Specialist (CCS), Certified Professional Coder (CPC) or other relevant credential, relevant experience, preferred.
2. RHIT, CCS, and/or CPC credential is required within one (1) year of the hire/transfer date. 
3. Once credentialed, maintains Registered Health Information Technician (RHIT) credentials,  Certified Coding Specialist (CCS), and/or Certified Professional Coder (CPC) or other relevant credential by completing continuing education requirements.

SUPERVISION RECEIVED

Receives minimal supervision from the Supervisor, HIM Coding.  Must be able to work independently.

SUPERVISION GIVEN

None

ESSENTIAL FUNCTIONS

1. Codes outpatient and emergency room charts.
   1. Analyzes and searches the documentation listed in the entire medical record for all documented clinical information (diagnoses and procedures) in accordance with established procedures, daily, for the Emergency Room and Outpatient Clinic.     
   2. Maintains standard coding accuracy rate of 95% according to the National Standard Coding Accuracy Rate.
   3. Internal and external auditing is performed on an annual basis.
2. Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.
   1. Enters accurate ICD-10 and CPT-4 codes, physician related and clinical information, and demographic information into computerized coding/abstracting system, in accordance with established procedures, maintaining a 95% accuracy rate, on a daily basis.
   2. Electronically releases accounts for generation of a patient bill after physician completion, as required.
   3. Processes and follows through with clinical codes and diagnostic information as records are returned by physicians, in accordance with established procedures, on a daily basis.    
   4. Standard of performance is as follows: 
      1. Trainee: Average ED-15 minutes per chart. Average clinic-3-4 minutes per chart. 
      2. Experienced: Average ED-8-9 minutes per chart. Average clinic-2-3 minutes per chart.  
3. Performs insurance billing activities. 
   1. Coordinates outpatient coding for Medicare, Blue Cross, Medical Assistance, HMO’s, and Commercial Insurance accounts.
   2. Reviews registration information at the time of coding for accuracy.
   3. Enters the coding into the system in preparation for electronic and hardcopy claims submissions following HIPAA guidelines.