Job Description

The Senior Coding Specialist is responsible for accurately assigning and sequencing ICD diagnostic and procedural codes and/or CPT procedural codes to inpatient and outpatient records.

Essential Duties and Responsibilities

• Code diagnostic and procedural information from the record using ICD-10-CM/PCS and CPT-4/HCPCS classification systems. Utilize a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines.
• Work cooperatively with the medical staff and other health care professionals in obtaining documentation to complete medical records and ensure quality coding.
• Select the DRG for each inpatient discharge and APC for each outpatient visit. Ensure coding compliance based on approved coding guidelines and conventions.
• Abstract medical data from the record to complete a discharge abstract on each inpatient, ambulatory surgery, emergency room, outpatient, and ancillary visit. Complete and verify diagnostic and demographic information.
• Enter patient information into computerized inpatient and outpatient medical record databases. Ensure accuracy and integrity of medical record abstract data prior to billing interface and claims submission.
• Routinely code Emergency Department records and enter E&M charges the majority of productive time. Meet productivity and quality standards for emergency department coding routinely. Code inpatient, outpatient surgery and ancillary records as determined by Coding Operations Manager.
• Provide compliance/documentation education sessions to physicians and hospital staff as requested.
• Investigate, respond to, and communicate information regarding coding, documentation, and compliance questions relating infusions and injections performed in the Emergency Department and OBV. Charge capture for Observation, Emergency Department.
• Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate.
• Attend other continuing education functions as necessary to maintain credentials, regardless of whether the educational programs are supported by the Department budget.

Education and Experience

Education: One of the following credentials are required – CCS, CPC, COC, RHIA, RHIT. Successful completion of a coding certificate program with AHIMA approval status is preferred.

Experience: Four or more years recent experience coding in an acute hospital setting required with coding ability demonstrated via a skills assessment. Must be able to operate or utilize fax machine, copy machines, microfiche reader/printer and Windows-based computer functions.