Job Summary: Under supervision, is primarily responsible for assigning accurate diagnosis and procedure codes to the patients health information record for Inpatient and Newborn records. May also be assigned the responsibility for assigning accurate diagnosis and procedure codes to the patients health information record for Outpatient records (Observation Hospital Ambulatory Surgery, Complex Hospital Outpatient Visit - Cardiac Catheterization PCI Lab, Interventional Radiology, Extended Emergency & Emergency Departments, as well as other select records).
This responsibility requires that the new coder be on-site for up to one calendar year and will require appropriate code assignment for physician-documented patient diagnoses, conditions and procedures; utilizing various coding classification schemes including ICD-10CM, ICD-10PCS, and HCPCS/CPT.
All work will be carried out in accordance with the: International Classification of Diseases - Official Coding Guidelines for coding and reporting as established by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS); American Medical Association (CPT); Office of Statewide Health Planning and Development (OSHPD); National Correct Coding Initiative (NCCI), and Kaiser Permanente organizational/institutional coding directives.
Ability to communicate with physicians in order to obtain clarification for diagnoses/procedures. Ability to understand the clinical content of the health record and abstract the data in the patient health information record data as well as perform other duties as assigned.
Essential Responsibilities:
• Upholds and maintains Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and all applicable state, federal and local laws.
• Reviews patient health information record to: identify and assign appropriate codes for diagnoses, procedures, and other services rendered, while also validating any Computer Assisted Code (CAC) assignments.
• Spends a minimum of 75% of work time assigning codes to Inpatient records.
• Appropriately sequences codes for diagnoses, procedures and other services as needed for proper MS-DRG, APR-DRG and APC assignment, utilizing the applicable coding conventions.
• Prevents errors, and if necessary, reviews OSHPD error correction reports within the scope of the assigned abstracting and coding function and makes corrections.
• Ensures that all abstracted and/or coded data are consistent with federal and state regulations (JCAH, Title 22), OSHPD reporting guidelines and organizational policy as it relates to the corporate compliance policy for accurate and complete coding.
• Interacts with physicians through established query process in order to clarify documentation supporting accurate patient diagnostic and procedure coding.
• Abstracts patient information into the computerized systems, in a manner ensuring the accuracy and integrity of the data.
• Ensures timely coded record availability according to regulatory guidelines, by meeting established coding and abstracting productivity standards.
• Ensures quality standards by meeting the established 95% coding accuracy and 98% completeness quality standards.
• Maintains and complies with HIPAA policies and procedures for privacy and confidentiality of all patient records.
• Attends and participates in selected national, regional and coding educational sessions.
• Works collaboratively with others on coding questions and issues.
• Demonstrates knowledge of system security, by complying with KP Electronic Assets Usage Policy.
• Maintains courteous and cooperative relations when interacting with others.
• Performs other duties as assigned.