The Coder II is primarily responsible for coding of outpatient surgical, interventional radiology / cardiology procedures and Observation accounts. Coder II is generally certified, but may be certification eligible. This position is responsible for reviewing the entire patient record including the electronic record to assign appropriate codes for the following areas: Outpatient: Day patients, cardiac catherterization lab, other interventional radiology and Observation patients. Coding should be complete, timely, and in accordance with CMS, Coding Clinic Guidelines, CPT Assistant, and organizational policies and procedures.
Education: High School Diploma or GED preferred. Completion of AHIMA approved coding.
Experience: Two years coding experience in an acute care facility outpatient surgery department, a stand alone ambulatory surgery center, or emergency/urgent care center, using ICD-10-CM, CPT coding, and APC grouper.
Knowledge and Skills: Data Entry proficiency. Medical terminology (basic and advanced). Human anatomy and physiology, pathology and microbiology required. Knowledge of ICD-10-CM & CPT 4. Ability to understand and interpret policies and procedures. Ability to interpret medical record documentation for accuracy and completeness.
License/Certifications: RHIT, CCS, or CPC Certificate required.
Equipment: Proficient in use of computers.
Physical Requirements: Must be able to perform the essential physical requirements of the job.