Coder Physician

Experienced pro fee coder with a minimum of 5 years of experience in coding for an academic trauma level 1 facility: 
-Surgical Pathology
-ENT (outpatient office services, including E/M and in-office procedures)
-Dermatology (outpatient office services, including E/M and in-office procedures)
-Pain (strong outpatient E/M & procedure coding experience)

Epic experience required.  A CCS, CCS-P or CPC coding credential required.  Schedule is M-F 8 hours day.  Shift times are flexible withing reason. MUST BE AVAILABLE DURING REGULAR BUSINESS HOURS PST FOR TRAINING THE FIRST WEEK.  6 month assignment with the option to extend.

JOB SUMMARY
Under general supervision the incumbent independently performs coding of patient’s
records to provide accurate physician, technical, supply, surgical and resident billing, and
reimbursement, while ensuring compliance. The incumbent’s work is performed in the
centralized clinic coding unit setting, which will include two or more of the following:
professional fees, technical fees, multi-specialties, surgical, and/or resident staff coding
and billing. Prior to submitting charges, the incumbent is required to review documentation
for all patient visits and procedures, identify all billable services, and discuss with the
provider when discrepancies occur in documentation. Codes and enters charges in the
online charge entry system. Responsible for working workques and charge reconciliation.
This position must have knowledge of the following system applications: Mainframe, EMR,
EPIC Charge Capture, Word, Excel, Internet Explorer, Images, CITRIX, •Quantim, Microsoft
Outlook, HIPAA Disclosures, and Incident Reporting.

Key Responsibilities - Total percent of time must equal 100%
% TIME Function Duties
80% REVIEW, ABSTRACT AND
CODE OUTPATIENT
RECORDS TO ENSURE DATA
QUALITY AND TO OPTIMIZE
REIMBURSEMENT
A-1 Reviews outpatient record to abstract medical, surgical, laboratory,
pharmacy, technical, service providers, demographic and social data
from the medical record within established standards, including but not
limited to, lag day policy and coding quality standards.
A-2 Distinguish surgical procedures and follow up care performed by
billable providers, residents, interns, and others.
A-3 Ensures that all diagnoses and procedures that impact
reimbursement are identified, sequenced correctly, and coded in an
accurate and ethical manner for appropriate reimbursement.
A-4 Researches and identifies correct codes for new procedures and/or
diagnoses
A-5 Assigns Evaluation and Management codes according to established
standards utilizing coding guidelines. A-6 Responsible for processing APC
charges using APC grouper.
A-7 Applies professional and technical guidelines as appropriate.
A-8 Consults with providers for clarification when conflicting or
ambiguous and/or significant missing documentation information is
identified. A-9 Assigns appropriate modifiers for both technical and
professional coding.
A-10 Applies State, Federal and internal UCDHS guidelines when coding.
15% CLINICAL CHARGE ENTRY B-1 Enters all charges into appropriate charge entry systems within
established standards.
5% MISCELLANEOUS C-1 Maintains a clean and well-organized work area
C-2 Performs other duties as assigned.
C-3 Attend mandatory coder education/training sessions
Other

Other Requirements - Applies to all Positions
• Performs other duties as assigned
• This job description is not intended to be a complete list of all responsibilities, duties or skills required for the
job and is subject to review and change at any time, in accordance with the needs of the organization
• Complies with all policies and standards
• Percentages of time allocated to functions are a guideline only. Individual assignments and time actually
worked in each functional area may vary based on the department’s operational needs

Ability to follow ICD-10, CPT and HCPCS guidelines related to assigning single, and sequencing multiple
diagnosis and procedure codes for appropriate professional and technical reimbursement and for data collection.
Ability to assign Evaluation and Management visit levels using the current guidelines.
Comprehensive knowledge of medical diagnostic and procedural terminology.
Knowledge of disease processes, anatomy and physiology, and medical terminology.
Ability to communicate technical and clinical billing information to physicians and clinical staff.
Ability to manage time schedules, deadlines, multiple requests, and priorities and to maintain productivity.
Excellent written and oral communication skills.
Abides by American Health Information Management Association’s established code of ethical principles to
safeguard the