Coder Level IV
- Company:
- The University of Vermont Health Network - Champlain Valley Physicians Hospital
- Location:
- Plattsburgh, NY 00129
- Post Date:
- March 22, 2024
- Description:
-
Under the general supervision of the Manager, HIM (Coding) and following established hospital and Department policies and procedures, a Coder Level IV is primarily responsible for coding and abstracting all inpatient discharges. During periods of staffing shortages or backlog in areas other than inpatient coding, a Coder Level IV may be assigned any of the following areas of outpatient coding by the Manager, HIM (Coding): Cardiovascular/Invasive Radiology Ambulatory Surgery/Procedure, non-cardiovascular/interventional radiology Ambulatory Surgery/Procedure, Observation (both Cardiovascular/Invasive Radiology and Medical), Emergency Care Center/Fast Track (technical and/or professional components), Ancillary/Clinic/OB-GYN/Medical Necessity or SNF accounts.
GENERAL CODING REQUIREMENTS
- Understands the principles of, and is able to assign, ICD-9CM diagnostic and procedural codes.
- Understands the principles of, and is able to assign, CPT-4 procedure and Evaluation and Management codes.
- Understands the principles of and is able to assign the MS-DRG or APR DRG as appropriate for inpatient accounts.
- Understands the principles of and is able to assign CPT-4 procedure and Evaluation and Management codes for technical and facility services as appropriate for outpatient accounts.
- Has a good working knowledge of Medical Terminology.
- Has a good working knowledge of Anatomy and Physiology.
- Ability to use online encoder, clinical abstracting system, MIS operating system, clinical and financial systems as needed.
- Maintains a working knowledge of governmental regulations, protocols and third party requirements regarding billing and billing documentation.
- Understands and is able to apply CMS documentation and coding guidelines specific to outpatient observation accounts
- Maintains an accuracy level of at least 93% for assigned primary coding duties.
- Maintains AHIMA productivity benchmarks for assigned primary coding duties.
- Completes AHIMA CE requirements for credential
- Maintains good rapport with the Medical and HIM Department staff.
- Maintains use of space, materials, supplies, and equipment. Requests repair and replacement as required.
INPATIENT RECORDS
- Accurately assigns and abstracts ICD-9 CM codes for principle diagnosis and/or principle procedure to inpatient accounts to ensure proper DRG reimbursement.
- Accurately assigns and abstracts ICD-9 CM secondary diagnosis/procedure codes as appropriate.
- Assures the most appropriate MS-DRG or APR-DRG is assigned to inpatient accounts.
- Accurately assigns and abstracts Present on Admission indicators, Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, type of anesthesia, and tissue specimen information as appropriate for inpatient accounts.
CARDIOVASCULAR/INTERVENTIONAL RADIOLOGY/VASCULAR OBSERVATION RECORDS
- Accurately assigns and abstracts ICD-9-CM diagnostic and CPT procedure codes for types of outpatient cardiology /interventional radiology/vascular procedures.
- Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen information as appropriate for outpatient records.
- Routes records to the appropriate area (i.e., logging, re-logging, data entry, recheck, or complete file).
MEDICAL OR GENERAL SURGERY / PROCEDURE OBSERVATION RECORDS
(NOT CARDIOVASCULAR / INTERVENTIONAL RADIOLOGY OBSERVATION RECORDS)
- Accurately assigns and abstracts ICD-9-CM diagnostic and CPT procedure codes as appropriate
- Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen information as appropriate for outpatient accounts.
- Routes records to the appropriate area (i.e., logging, re-logging, data entry, recheck, or complete file).
GENERAL AMBULATORY SURGERY/PROCEDURE RECORDS
(NOT CARDIOVASCULAR/INVASIVE RADIOLOGY/VASCULAR)
- Accurately assigns and abstracts ICD-9-CM diagnostic and CPT procedure codes.
- Accurately assigns and Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen Information for outpatient records.
- Routes records to the appropriate area (i.e., logging, re-logging, data entry, recheck, or complete file).
EMERGENCY CARE CENTER/FAST TRACK RECORDS
- Accurately assigns and abstracts ICD-9 CM diagnostic and CPT procedure and Evaluation and Management codes for facility services.
- Accurately assigns and abstracts ICD-9 CM diagnostic and CPT procedure and Evaluation and Management codes for professional services.
- Accurately assigns and abstracts Discharge Status Codes, Attending Physicians, Consultants, Surgeons, Assistant Surgeons/First Assist, Anesthesiologist, Anesthesia stop and start times, type of anesthesia, and tissue specimen information as appropriate for Emergency Care Center/Fast Track accounts.
ANCILLARY SERVICES/CLINICS/OB-GYN/MEDICAL NECESSITY
- Accurately assigns and abstracts appropriate ICD-9-CM diagnostic and CPT procedure codes for Ancillary Services/Clinics/OB-GYN/Medical Necessity accounts.
- Performs Medical Necessity review and follow-up per ICD-9 CM coding guidelines and conventions and HIM Coding policy and procedure.
SKILLED NURSING UNIT RECORDS
- Accurately assigns and abstracts ICD-9-CM diagnostic and procedure codes for CVPH SNF patient accounts.
- Regularly reviews SNF in-house records and codes additional diagnoses as needed.
- High School Diploma required.
- Successful completion of medical terminology, anatomy and physiology classes.
- Working knowledge of ICD-9CM and CPT coding guidelines and conventions.
- Understanding of Medical Necessity for Medicare targeted tests.
- CCS, CCS-P, RHIT or RHIA credential.
- A minimum of one year of experience coding inpatient accounts in an acute care setting; PLUS A minimum of three years experience coding Cardiovascular/Interventional Radiology/Vascular Ambulatory Surgery/Procedure/Observation, Medical or General Surgery Observation, General Ambulatory Surgery/Procedure (not cardiovascular/interventional radiology/vascular), Emergency Care Center/Fast Track (technical and professional components), Ancillary Services, Clinics, OB-GYN, Medical Necessity and SNF accounts.
- Ability to achieve and maintain a 93% accuracy level while meeting AHIMA productivity benchmarks for assigned primary coding duties.
- Other duties as assigned by the Coding Manager.
- Work requires a high degree of interpersonal skills to interact with the Medical Staff, co-workers and staff from other departments.
As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.
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