Coder Medical Records Job Description
Coder medical records
provides education to health care providers in understanding ICD, CPT, HCPCS coding guidelines, practices and proper documentation guidelines and terminology.
Coder Medical Records Duties & Responsibilities
To write an effective coder medical records job description, begin by listing detailed duties, responsibilities and expectations. We have included coder medical records job description templates that you can modify and use.
Sample responsibilities for this position include:
Performs in depth analysis of medical records to abstract diagnoses and procedures for accurate billing based on CPT and ICD-10 guidelines
Identifies training opportunities for internal and external stakeholders related to federal guidelines, best practices, and medical record documentation requirements
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions
Uses thorough knowledge of coding systems and edit logic to assign appropriate codes
Applies a comprehensive body of rules, procedures, and operations related to health information management, medical records activities and computerized data entry and retrieval systems
Code complicated medical records that are difficult to classify using official coding conventions and guidelines
Applies the Uniform Hospital Discharge Data Set definitions any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record
Assigns ICD-10-CM or HCPCS codes, creating APC group assignments
Ensures that Inpatient diagnoses and procedures are coded in accordance with the Coding and Reporting Official Guidelines based on the Uniform Hospital Discharge Data Set (UHDDS) definitions for principal and additional diagnoses
Keeps abreast of coding guidelines and reimbursement reporting requirements, and brings identified concerns to manager for resolution
Coder Medical Records Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Coder Medical Records
List any licenses or certifications required by the position: CPC, AAPC, AHIMA, CRC, COC, CIC, RHIT, RHIA, HCS-D, CCS
Education for Coder Medical Records
Typically a job would require a certain level of education.
Employers hiring for the coder medical records job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Education, Department of Education, Health, Medical, Health Information Management, Health Information Technology, Associates, Medical Terminology, Anatomy, Health Information Administration
Skills for Coder Medical Records
Desired skills for coder medical records include:
Anatomy and physiology
Medical terminology
Pharmacology
Medical terminology and general understanding of the health record
Coding systems and edit logic to assign appropriate codes
Clinical disease processes
CPT
Sequencing diagnoses and procedures as outlined in the Official Coding Guidelines
Telephones
Fax machines
Desired experience for coder medical records includes:
Accurately codes for the professional vs
RHIT, CCS or RHIA Certificate preferred or other or exp
Serves as final auditing arbiter regarding the Risk & Recovery's Retrospective Risk Adjustment (RA) Coding Team
Collects and analyzes data obtained from onsite provider visits to formulate recommendations and solutions based on audit trends and results
Provides feedback to Risk & Recovery leadership on performance improvement opportunities as a result of performance gaps
Acts as a subject matter expert to internal and external stakeholders in the area of federal requirements and best practices
Coder Medical Records Examples
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Coder Medical Records Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of coder medical records. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for coder medical records
- Maintain up to date knowledge of new medical technology, official coding rules, NCCI edits and LCD’s, and all third party payor guidelines
- Three (3) Year Experience ICD-9-CM and CPT-4 Coding System
- Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements
- Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record
- Participates in and represents the department in business leadership groups, including external professional groups specializing in coding and provider education
- Assists the business with research and documentation of workflows and policies and procedures
- Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information
- Maintain a thorough understanding of medical record practices, standards, regulations, The Joint Commission, Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC)
- Confers with Physicians and other providers to obtain greater specificity and/or clarification on possible diagnoses and procedures
- Insures integrity of all data prior to transmission
Qualifications for coder medical records
- 2+ years of CCS or ability to obtain/equivalent experience
- Two years experience in coding/abstracting inpatient records in an acute care facility
- Requires BA/BS in health sciences, health management, or nursing, 3-5 years of ICD-9 coding or medical record audit experience in a consultative role
- CPC from accredited source
- Requires that you reside in Polk County, Florida, and be willing to travel within assigned territory approximately 50% of the time
- SME for all coding specialties like E/M, radiology, anesthesia and should possess good communication skills
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Coder Medical Records Job Description
Job Description Example
Our innovative and growing company is hiring for a coder medical records. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for coder medical records
- Have working knowledge of medical terminology, anatomy and physiology, and mental and behavioral disorders
- Responsible for review of Medical Records to identify the most appropriate ICD10/CPT codes associated with the level of the visit
- Adhere to CMS and organizational regulations associated with ICD10/CPT coding for submission and reimbursement
- Assure accurate and complete assignment of CPT codes and modifiers that are supported by medical record documentation for outpatient records
- Responsible for review of Medical Records
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided
- Puts on hold records not coded due to “missing documentation”
- Reports queries pending physician response > 48 hours to manager
- Monitors and corrects any discrepancies on the accounts in CPA Discern Notification queue
- Assists manager in maintaining goals for Accounts on the DNFC/DNFB
Qualifications for coder medical records
- Act as a highly skilled specialist in specialties in coding should train people on new automation process when there is business requirement
- Data entry/CRT Level Characteristics N/A
- Successful completion of coding certification program with AHIMA approval status
- Two years experience in health information and data entry in medical record procedures or equivalent education and experience preferred
- 1-2 years in the HIM (Medical Records) Department in an acute care facility required
- Type 45 w.p
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Coder Medical Records Job Description
Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of coder medical records. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for coder medical records
- Assists in addressing PRO correspondence regarding DRGs and Coding
- Assists in reviewing and correcting any information for the Agency for Healthcare Administration (AHCA)
- Assists in conducting periodic coding quality studies
- Reports noncompliance issues detected through auditing and monitoring to manager
- Uses the Optum Code Finder
- Computer, laser printer, fax machine, copy machine
- R.H.I.T., C.C.S., R.N or equivalent experience
- Three (3) Year Experience minimum Medicare Inpatient records (Preferred)
- Graduation from an accredited R.H.I.T
- Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary
Qualifications for coder medical records
- Knowledge of general office procedures and filing systems
- Thorough knowledge of confidentiality rules and knowledge of State and Federal Laws governing release of medical information
- CCAT licensure/certification
- Other (Application for Associated Health Occupations - VA Form 10-2850c)
- Fort Washakie, WY
- Eagle Butte, SD
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Coder Medical Records Job Description
Job Description Example
Our company is looking to fill the role of coder medical records. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for coder medical records
- Review and research the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-9-CM/ICD-10 CM and/or CPT, HCPCS coding conventions and payer specific coding guidelines
- Develop and maintain a thorough understanding of payer specific guidelines as it pertains to edit review and denial management
- Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement
- Continuously maintain an hourly productivity average consistent with the departmental coding standards (The productivity standards will be available in the Radiology Coding Billing Office)
- Review, research and correct insurance company coding denials
- Other coding and billing related duties or projects as assigned
- Review medical record documentation and accurately code the primary/secondary diagnoses using ICD-10-CM coding conventions
- Consult with clinicians and colleagues on coding practices and conventions in order to provide appropriate coding information
- Identify coding and documentation deficiencies/opportunities and notify providers to communicate suggested coding improvements to enable compliance and billing
- Assist with the continuous quality improvement process to identify coding training needs of facility staff and providers
Qualifications for coder medical records
- CCS (Certified Coding Specialist) or
- RHIA, RHIT, CCS, CCS-P and/or CCA
- 3-5 years recent coding experience in an acute care hospital setting
- CPC (Certified Professional Coder) or any other coding certification through AAPC or AHIMA required
- Nursing or clinical experience preferred
- Review and provide CPT and ICD10 code abstracting for Outreach Anatomic Pathology cases to ensure regulatory compliance is satisfied prior to reporting and billing
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Coder Medical Records Job Description
Job Description Example
Our company is searching for experienced candidates for the position of coder medical records. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for coder medical records
- Translate patient information into ICD-9-CM, ICD-10-CM, and DSM-5 codes
- Accurately assign the proper code and DRG, and enter into Meditech/3M a minimum of 6 discharge charts per hour
- Print daily report from Meditech with list of patients already discharged and requiring final coding
- Scan loose documents into "Additional Documents” section of patients’ charts in TIER
- Help process requests for PHI received – Log requests into Meditech
- Communicate and interact with coworkers within the department and other departments in a respectful and helpful manner regardless of position or discipline
- Any and all other job related functions as required by the Manager of the Health Information Management Department
- Confers with Physicians, residents and billing providers to obtain greater specificity and/or clarification on possible diagnoses and/or procedures performed to ensure accurate coding
- Performs other related duties, which may be inclusive, but not listed in the job description
- Responds to inquiries, both in person and when answering phone, according to departmental policies
Qualifications for coder medical records
- Work with the Outreach Support Services Billing Supervisor to ensure complete and accurate coding and edit(s) resolution
- Utilize NorthShore LIS, EMR, and Billing Systems (PowerPath, EPIC, SoftLab)
- Assist with Billing Department and Outreach Support Services general duties as needed
- Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialists (CCS) or Certified Professional Coder (CPC) required
- One year of medical coding of Outpatient services preferred
- Experience in Anatomic Pathology and/or Dermatopathology preferred