Job Summary
This position assigns appropriate billing codes for an acute care, periop, or outpatient unit(s), clinic(s) or medical office(s) system-wide. Evaluates medical records, provider notes and dictation to determine appropriate procedure codes to assign to patient records and bills. Uses coding software and the companys Charge Description Master (CDM) to create billings and charges for insurers, government agencies and other payors.
Essential Functions
Reviews patient records, dictated report(s), physician/provider notes. Uses a standard listing of procedures/charge codes and/or an automated system with the companys programmed Healthcare Common Procedure Coding System (HCPCS) for all commonly used Diagnosis Related Groups (DRGs).
Identifies opportunities for improvement in clinical documentation. Shares that information with the appropriate Revenue Integrity staff. Maintains a current knowledge of procedural terminology requirements and documentation requirements.
Works with other point of service charging/coding staff to maintain consistency in practice across the system.
Works as a member of the system team to provide services and achieve goals. As assigned, may manage supply chain functions, scheduling, provide patient services or administrative support.
Minimum Qualifications
High school diploma/GED or equivalent working knowledge.
Requires a level of knowledge normally gained over two or more years of related work in the same type of clinical, medical office or acute care unit. Must be knowledgeable of medical terminology and current regulatory agency requirements for coding and charging for the assigned clinical area, and have a good understanding of reimbursement methodologies. Requires strong abilities in reading, interpreting and communicating, as well as effective interpersonal skills, organizational skills and team working abilities.Requires strong abilities in reading, interpreting and communicating, as well as effective interpersonal skills, organizational skills and team working abilities.
Must be able to work effectively with common office software, coding and billing software, and the electronic medical records system.
Preferred Qualifications
Current Procedural Terminology (CPT) coding experience in a similar setting and Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) credentials preferred for some assignments.
Additional related education and/or experience preferred.
