The Medical Coder Specialist will
have frequent and daily interactions with internal and external clients
including but not limited to Physician and Non-Physician Providers.
Responsibilities include primary diagnosis and procedural coding for the
designated major specialty areas. Clinical abstraction coding is defined as
identification of codes based solely on the source documentation for CPT and
DUTIES AND RESPONSIBILITIES:
- Primarily code from final encounter
reports signed by the provider.
- Review the complex (problematic
coding that needs research and reference checking) medical records and
accurately codes the primary/secondary diagnoses and procedures using ICD-9-CM
and/or CPT coding conventions.
- Maintain a thorough understanding of
anatomy and physiology, medical terminology, disease processes, and surgical
techniques through participation in continuing education programs to
effectively apply ICD-9-CM and CPT-4 coding guidelines to inpatient and
outpatient diagnoses and procedures.
- Correlate information from approved
supporting clinical documentation not limited to Radiology and/or other
Physician Consultations after review by the Attending Physician, wherever
- Provide education/training to physicians
and other providers on coding and clinical documentation. Consult with and educate/train physicians on
coding practices and conventions in order to provide detailed coding
- Communicate with nursing and
ancillary services personnel for needed documentation for accurate coding.
Provide real-time feedback to procedural providers as it pertains to proper
coding and clinical documentation of services performed.
- Engage in provider/department
contact and education as the primary liaison for clarification of
documentation, including documentation deficiencies.
- Mentor and assists in training of
other coders within the department.
- Participate in the development of
coding policies and procedures as identified.
- Coordinate/mentor the work of designated
coding employees to ensure quality and quantity of work performed through
- Assist with research and development
of presentation materials for continuing education programs for physician in
their areas of specialization.
- Interact with and provides
high-level analysis of trends to Management, Revenue Managers and others about
Coding related issues.
- Perform other related duties
incidental to the work described herein.
Bachelor degree in medical record administration or
associate degree in medical record technology or one year coding diploma or
courses in Medical Terminology, Anatomy & Physiology with extensive
training in coding.
Requires four years of coding experience, with at least two
of those years in primary care abstraction (physician or medical group in
multi- specialty practices, i.e., Internal Medicine, Family Medicine,
Pediatrics, OB/GYN, etc.).
LICENSURE, AND/OR CERTIFICATION:
Registered Health Information Administrator (RHIA) or
Registered Health Information Technician (RHIT) or Certified Coding Specialist
(CCS) or Certified Professional Coder (CPC)
SKILLS, AND ABILITIES:
Extensive knowledge of coding procedures, applicable
modifiers in multi-specialty setting
Understands and apply appropriate Center Medicare Services
guidelines to coding
Advanced ICD-9-CM & CPT-4 coding conventions
Anatomy and Physiology
Extensive DRG/APC reimbursement knowledge
Coding software familiarity
Effective written and verbal communication skills