Job Title: Coder/Abstractor
Department: Health Information Management
Reports To: Coding Supervisor, Health Information Management Director
The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing. Responsible for concurrently and retrospectively coding inpatient, outpatient (Observation) (Surgical Day Care), Emergency Department, physician clinic, hospitalist accounts, and ancillary medical records and abstracting information into the hospital information system. Will also be responsible with assisting other Health Information Management Department functions as needed.
Ages Specific To Department:
Birth through 1 Month
13 years through 17 years
18 years through 34 years
35 years through 50 years
51 years through 69 years
70 years +
Employee will work with patients/employees of all cultural and religious backgrounds.
Ethics And Compliance
Employee performs within the prescribed limits of Cody Regional Health’s Ethics and Compliance Program. Is responsible to detect, observe and report compliance variances to their immediate supervisor, or upward through the chain of command, the Compliance Officer or hospital hotline.
All employees must adhere to the Mission, Vision and Key Values of Cody Regional Health.
- Assist Utilization Review with concurrent coding of inpatient/outpatient medical records utilizing the ICD Code book.
- Responsible for the final coding of all CRH physician, hospital, CMC and LTCC medical records utilizing: ICD, CPT Code, and HCPCS coding books, the 3M encoder and the computer system.
- Provides ongoing education and follow-up to physicians regarding E&M coding levels and medical necessity guidelines.
- Identifies services and procedures provided but not adequately documented in the health record. Advises Department director of documentation deficiencies.
- Identifies trends and ongoing problems related to medical documentation and recommends possible solutions.
- Responsible for abstracting designated medical records information into the computer system (may include, but not be limited to, verifying that the discharge status is correct, name of anesthesiologist on surgical cases, referring and consulting physicians, blood and blood products codes, diagnosis codes, surgery date and type of anesthesia administered, and procedure codes).
- Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
- Monitors unbilled accounts for outstanding or uncoded visits to reduce accounts receivable days for all patients.
- Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
- Analyze records for Medical Staff quality indicators.
- Maintains data, department activities, and all patient information in a confidential manner.
- Consistently following established procedures.
- Other duties as assigned.
- Attends all education set up by supervisor or department director as well as any other educational opportunities that benefit job performance.
- Maintains coding credentials as well as continuing education hours.
- Responsible for assisting with other Health Information Management Department functions, as requested.
Minimum of successful completion of a coding certificate program in a program with AHIMA or AAPC approval status. Coding certification status preferred. Coding certification preferred from AAPC, American Health Information Management Association or the ability to sit for the examination within one year of employment. Prefer someone with work experience as a coder or strong training background in coding and reimbursement.
Two years ICD and CPT coding experience and strong medical terminology knowledge preferred. One year medical records abstracting experience preferred. Experience working in an acute care hospital or physician clinic working with networked computer system or 3M encoder and computer experience.
The ability to complete coding within predetermined time frame and accurately assign codes. Display ability to work independently and to manage time well. Good communication skills and the ability to get along well with others. Knowledge of the revenue cycle, charge master, manual coding skills, encoder systems, and DNFB. Thorough knowledge of CPT, current ICD coding system and HCPCS systems
Coding certification preferred from AAPC, American Health Information Management Association or the ability to sit for the examination within one year of employment.