The Coder II is certified and is responsible for Inpatient coding. The Coder reviews the entire patient record including the electronic record to assign appropriate codes for Inpatients, Observation, Outpatient Surgeries, Cardiac Catheterizations and Interventional Radiology. 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 program.
Experience:Two years coding experience in an acute care facility using ICD-10 and APC's required.
Knowledge and Skills: Data Entry proficiency with 3M APR DRG software. Knowledge of MS-DRG methodology, Severity of Illness and Risk of Mortality Methodology and PCS coding. 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 polices 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.