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Accurate assignment of ICD-10-CM/PCS, CPT-4 codes, HCPCS and Modifiers to the highest level of specificity as supported by documentation in the medical record in compliance with governmental regulations and hospital policies. Review of the quality of data and documentation and facilitate improvement. Responsible for reviewing medical records/assigned charges as necessary, for accuracy.

Essential Functions:

1. Understands and is able to apply inpatient, emergency room, observation, day surgery and clinic/outpatient coding guidelines depending upon the patient type being coded.
2. This position is able to fill in when other coders are out of office.
3. Codes RFV (Reason for visit), which are the patient's own words on why they are presenting for services.
4. Codes as the principal diagnosis "The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care", adhering to Cibola General Hospital's Coding, Abstracting, Data Retrieval Policy and Procedure and AHIMA's Standards of Ethical Coding.
5. Secondary diagnosis (es) and operative procedure(s) in the medical record for clarification, agreement, co-morbidities/complications, and additional information.
6. Identify reasons that account cannot be coded/abstracted and places cases not final coded on hold with the appropriate hold reason. Notifies HIM Director of reasons/issues with uncoded accounts.
7. Queries the attending physician utilizing the Cerner message center for further clarification or help as needed for greater specificity, clarification or correct sequencing of codes utilizing a compliant query process
8. Enters final coding and abstracting information utilizing 3M accessed through the Cerner electronic medical record (EMR).
9. Assists in training new or contract coders when the Lead Coder is unavailable.
10. Maintains a 95% coding accuracy rate or higher.
11. Codes off of the assigned coding queue(s) in Cerner but is able to run a Discharged Not Final Coded (DNFC) list daily and as necessary to identify all accounts not coded/abstracted.
12. Codes and abstracts both discharged inpatient and outpatient charts within 3 days of discharge. Notifies HIM Director of issues affecting the ability to code discharged charts.
13. Assists HIM and PFS Directors in addressing coding errors on denied claims.
14. Helps to maintain hospital charge master (in requesting codes that do not exist in charge master, that need to be added).
15. When requested will provide support services to hospital administration on a variety of special projects related to improving operational and financial performance.
16. Performs Performance Improvement projects as needed and understands performance improvement process at Cibola General Hospital.
17. There are other duties, while not considered essential for this position, are required as part of the function of this position.

Position Qualifications:

Education and/or Experience:

1. Current RHIT, CCS, CCS-P or CPC certification required; extensive knowledge of medical terminology, anatomy and physiology; disease processes and a minimum of 3 years of inpatient and outpatient coding experience.
2. Knowledge of ICD-10-CM/CPT/HCPCS, assigning modifiers, and prospective payment systems.
3. Strong computer skills with knowledge of Microsoft Outlook, Word, Excel and 3M.
4. Ability to work with detail.

Physical Requirements:

Occasionally

Frequently

Constantly

Walking X

Sitting X

Standing X

Stooping X

Bending X

Kneeling X

Crouching X

Twisting X

Climbing Stairs N/A

Climbing Ladder/Scaffolding NA

Stretching/Reaching X

Pushing/Pulling X

Hearing X

Speaking X

Seeing (colors, brightness, details) X

Hand-finger dexterity X

Lifting/Carrying up to:

• 20 lbs.
• 30 lbs.
• 40 lbs.
• 75 lbs.
• 100 lbs.
• > 100 lbs.

Exposure to blood borne pathogens

Typically no exposure, but working in a healthcare facility there is limited potential.

Exposure to dust

Exposure to fumes

Exposure to noise

Exposure to chemicals/ hazardous materials

Typically no exposure, but working in a healthcare facility there is limited potential.

Other

N/A