Under general supervision, the Coder II is responsible for the timely review of medical record documentation to abstract demographic data and assign diagnoses, procedures, and modifiers for statistical classification and reimbursement purposes. Ensures the accuracy of the reason for admission, extent of care received and level of severity of illness. Utilizes software applications, electronic and printed coding references to perform coding related tasks.
- Selects appropriate assignments for coding/abstracting from work queues.
- Uses 3M Encoder, various software applications, electronic and printed coding references to accurately code diagnosis and procedures for patient encounters; accuracy of selection/sequencing of principal and secondary diagnosis is expected to be at 98% accuracy while maintaining productivity requirements as outlined by management and administration.
- Contacts physician and/or ancillary departments when additional information is needed to accurately code the record.
- Strives to decrease pending accounts on all patient types.
- Completes record or reassigns record to appropriate work queues 100% of the time.
- Maintains patient, medical record, department and employee confidentiality at all times.
- Provides feedback regarding documentation and coding.
- Successfully completes requirements for maintaining credentials.
- Attends and participates in department meetings; responsible for all information communicated at the meetings; attend all mandatory meetings and training.
The above statements are intended to describe the general nature and level of work performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified and employees may be required to perform other duties as assigned.
SKILLS, KNOWLEDGE, AND ABILITIES
- Possess and applies a thorough knowledge of coding, coding guidelines and compliance
- Thorough knowledge Anatomy & Physiology and medical terminology
- Knowledge of encoder and data abstracting software
- Ability to interact with physicians and ancillary departments
- Ability to work with all persons in and out of the department
- Ability to work independently
- Strong oral and written communication skills
- Capable of reading and interpreting coding guidelines