Senior Coder

Senior Coder

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records.

Job Responsibility

• Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
• Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.
• Utilizes resources and reference materials (e.g., manuals, online resources: Official Coding Guidelines (OCG), AHA Coding Clinic, Center for Medicare Services and CPT Assistant) to identify appropriate codes and reference code applicability, rules and guidelines.
• Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record.
• Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures.
• Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.
• Makes determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process.
• Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment.
• Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations.
• For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.
• Assigns appropriate discharge physician in the system.
• Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations.
• Demonstrates basic knowledge of the impact of coding decisions on revenue cycle.
• Assists in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity of illness and risk of mortality as indicated.
• Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations.
• Completes moderately complex assignments that require an ability to recognize the need to occasionally deviate from accepted practices.
• Exercises independent judgment on basic or moderately complex issues regarding job and related tasks.
• Works independently under minimal supervision within established guidelines and procedures.
• Requires minimal instruction on day-to-day work; majority of work is self-directed; receives instruction on new assignments.
• Works with lead on resolution of day-to-day technical/procedural challenges.
• May provide work guidance to team members to ensure accurate and timely completion of tasks.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

• High School Diploma or equivalent, required.
• 3-5 years of technical experience, required.
• Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCSP) or Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC) or Certified Coding Associate (CCA) or RHIA or RHIT certification, required.

Key skills/competency

• Medical Coding
• Diagnosis Selection
• Procedure Coding
• Medical Records Analysis
• Anatomy and Physiology
• Official Coding Guidelines
• CMS Regulations
• Revenue Cycle Management
• Physician Queries
• CPT Codes