This position is responsible for reviewing clinical documentation and applying the correct coding and modifiers for clinical services performed in office and/or hospital setting an may include surgical and non-surgical procedural services. This position ensures that the documentation supports the levels or types of service billed, ensures the documentation is compliant with regulatory regulations, provider documentation guidelines, and CPT documentation and CMS coding guidelines
Job Relationships
Reports to the Coding Unit Manager
Principal Responsibilities
- Responsible for reviewing and analyzing documentation present in the medical record for professional services related to clinic, inpatient and/or outpatient services.
- Verifying and coding of the diagnosis, evaluation and management, procedures or other codes required for the completeness and accuracy of the record.
- Codes and/or reviews encounters to identify first-listed diagnosis, co-morbidities, complications, therapeutic and diagnostic procedures with International Classification of Diseases (ICD10), Current Procedural Terminology (CPT), Heath Care Financing Administration Common Procedure Coding Systems (HCPCS – all levels, and any other coding classification systems that may be required).
- Examine all documents in the record for authorized signature and patient identification to ensure all documents contain sufficient documentation to support the diagnosis and treatment administered, and the results obtained are adequately described.
- Communicates with hospitals/physicians to obtain additional documentation when needed to complete coding documentation requirements.
- Responsible for charges to be posted in a timely fashion as directed by the Manager.
- Assist other staff employees as necessary including training fellow coders in specialties of expertise.
- Assist the Director or Manager with all projects in related scope of job knowledge and responsibility.
- Comply with the Springfield Clinic incident reporting policy and procedures.
- Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
- Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
- Perform other job duties as assigned.
Education/Experience
- High School graduate or GED minimum required: College degree in health-related field preferred.
- Coding experience in Professional & Facility Coding
- 2 years of experience as a certified coder preferred
Licenses/Certificates
- Must have one of the following AHIMA or AAPC certifications: CPC, CCS, CCS-P, RHIT, RHIA
Knowledge, Skills and Abilities
- Expert knowledge of CPT, HCPCS, E/M leveling, Modifiers and ICD-10-CM diagnostic coding required.
- Proficient computer skills using MS-Word, Excel, PowerPoint, Outlook, Teams, Microsoft Edge, and EncoderPro.
- Preferred knowledge using Athena, Ingenious Med and RCX.
- Utilize Official Guidelines for Coding and Reporting, Coding Clinics and CPT for coding accuracy.
- Provide excellent customer service internal and external and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
- Strong analytical and communication skills.
- Attend, as directed, conferences, in-services and workshops toward further professional development and job knowledge.
- Maintain credentialing CEUs
- Follow all Clinic operation procedures and policies.
Working Environment
- In office, remote optional based off productivity/accuracy standards
PHI/Privacy Level
HIPAA1
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