Medical Records Coder II

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

About Duke Health's Patient Revenue Management Organization

 

Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions.

 

The Medical Records Coder II is a certified Coder.

The HIM Coder II utilizes experience, education, coding guidelines and Duke coding policies and procedures to perform all daily duties.

Performs evaluation and review of medical record documentation to accurately assign codes for the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II.

Sequence the diagnoses and procedures using coding guidelines and ensures DRG or APC assignment is accurate.

HIM Coder Tech II focuses their work on capturing data with consideration for regulations and requirements to support medical necessity and reimbursement.

 

 

Duties and Responsibilities of this Level:

Review medical record documentation and accurately assign codes for the primary/secondary diagnoses and procedures using ICD-10-CM, CPT-4 and HCPCS Level II.  Sequence diagnoses and procedures using coding guidelines.  54 % of time spent

Maintain competency in ICD-10-CM, CPT-4 and HCPCS Level II and knowledge of reimbursement reporting requirements. 95% Minimum quality.

Maintain a thorough understanding of anatomy and physiology, medical terminology, pharmacology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM coding guidelines for assignment of outpatient diagnoses and CPT-4 and HCPCS Level II for procedures.

Knowledge coding and charging requirements to ensure accurate code submission along with management of edits and denials. Processing claim edits. 4% of time spent

 

Researching and processing denied claims to correct and resubmit. 5% of time spent

 

Processing IP conversions from IP status to Observation can be up to 20% of time spent.

 

 

Knowledge of UHDDS definitions and data requirements to support accurate coding and data collection. Assignment/validation of correct discharge disposition based on UHDDS guidelines. 2% of time spent

Knowledge of NCD/LCD edits to support compliance with medical necessity requirements.

Apply knowledge of all coding reference materials and education to problem solve unique or new cases resulting in the assignment of appropriate diagnosis and procedure codes. Validation of applicable hard coded CPT codes.  5% of time spent

 

Use logic and reasoning to demonstrate critical thinking in the assignment of diagnosis and procedure codes with consideration for reimbursement, quality and other data capture requirements. 5% of time spent

 

Recommend cases that need to be queried of the physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. 5% of time spent.

 

 

Maintain compliance with quality and quantity standards as outlined in Hospital Coding Policies.

Abide by the Standards of Ethical Coding as set forth by the American Health Information Management   Association and adheres to official coding guidelines.

 

Perform other related duties incidental to the work described herein.

 

Education:

 

 

 

Associates degree in health information management or High School