Coding Tech | Inpatient

Job Duties and Responsibilities

• Codes patient data utilizing EPIC systems to ensure optimal reimbursement to the hospital.
• Meets productivity standards
• Abstracts data from the patients' medical record using the 3M computerized abstracting system to compile accurate and timely statistical data.
• Verifies accuracy of information by identifying such things as patient's name, DOB, hospital billing account number, medical record number and location in hospital to ensure proper chart is processed.
• Reviews medical charts for deficiencies and completes appropriate forms as directed by Coding Manager and/or Department Manager.
• Performs other related duties as needed to support the achievement of department goals and objectives.
• Reads the coding updates as received on a monthly basis.
• Stays apprised of changes in the CPT/HCPCS, modifiers, NCCI edits, and ICD-10-CM coding nomenclatures.
• Complies with the Coding guidelines and Billing Compliance standards of GMC.
• Follow five fundamentals of patient communication: Acknowledge, Introduce, Duration, Explanation, Thank You (AIDET)
• Practices and promotes the culture of safety.
• Supports, promotes, and adheres to the Standards of Behavior.
• Adheres to the National Patient Safety Goals.

Required Licenses and/or Certifications

One of the following coding credentials, recognized by American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC):

• Certified Professional Coder (CPC)
• Certified Outpatient Coder (COC)
• Certified Coder Specialist \u2013 Physician (CSS-P) with appropriate level of experience.

Required Work experience

A minimum of two (2) years' experience in the outpatient setting (Physician's office or ambulatory surgery centers) within the last five years, including assignment of E & M, CPT, and HCPCS codes.

Multiple specialties encompass different medical specialties (i.e. Family Practice, Pediatrics, Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes.

Ancillary specialties (PT/OT, Radiology, Lab, Nutrition, etc.) that usually do NOT use E & M codes do not count as qualifying experience.

Additionally, coding auditing and training exclusively for specialties such as home health, skilled nursing facilities, and rehabilitation care will not be considered as qualifying experience.

Coding experience limited to making codes conform to specific payer requirements for the business office (insurance billing, account receivable) is not a qualifying factor.

Required knowledge, skills, and abilities

Working knowledge of coding/abstraction, medical terminology, ICD-10-CM, CPT, APCs and DRGs

Knowledge of human anatomy, physiology is required

Strong computer skills (Microsoft Office products)

Effective interpersonal communication skills to acquire needed information and maintain cooperative work relationships with physicians

Excellent communication skills

Exceptional organizational/Time management skills, verbal and written communication skills required

Ability to organize work priorities and meet specific objectives under time constraints

Ability to manage multiple tasks simultaneously

Good problem-solving skills and attention to detail

Ability to be a team player in a team-oriented environment

Proficient at 10 key

Ability to use fax, photocopier, PC, microfiche reader/printer, scanner

Preferred qualifications

Prefer experience in a hospital and clinic setting

Functional Demands

Population(s) served

Neonatal, pediatric, adolescent, adult, and geriatric.

Physical demands

Lifting:

Occasional: maximum of 30 lbs. from floor to chest height, 1 x year.

Frequent: none

Items lifted- box of records.

Transfers: None

Push/Pull: Minimal force required to pushcart of records, 1 x day for 300 yards.

Carry: Maximum of 3 lbs. for 100 yards. Medical records and papers.

Computer: 95% of day, 20% mouse, 80% data entry.

Fine Motor: High degree for data entry, manipulations papers, clips, etc.

Standing: Up to 1 hour at one time and 1 hour in one day.

Sitting: Up to 3 hours at one time and 7.5 hours in one day.

Kneeling: Up to 1 minute at one time and 20 minutes in one day.

Stooping: Up to 1 minute at one time and 20 minutes in one day.

Driving: None.

Climbing: Up to 1 minute at one time and 2 minutes per day.

Other: Constant talking, hearing, and seeing to interact with staff, physicians, patients, and vendors.

Environmental conditions

Locations: Inside.

Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. Occasional pressure to meet deadlines. Requires judgment and action. May be exposed to unpleasant customers.

Minimal exposure to biohazardous materials.

Some exposure to cleaning chemicals and dust.

Organizational Expectations

• Provides a positive and professional representation of the organization.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.
• Maintains hospital standards for a clean and quiet environment.
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope-of-practice or job role.
• Participates in ongoing quality improvement activities.
• Maintains compliance with organization's policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards.
• Complies with organizational and regulatory policies for handling confidential information.
• Demonstrates excellent customer service through their attitude and actions, consistent with the standards contained in The Gritman Way.