Coding Technician III-Medical Records

Summary

JOB SUMMARY The Coding Technician III follows thorough review of documentation in a medical record, accurately selects and sequences diagnosis and procedure codes using the current version of ICD CM / PCS or CPT.

Communicates to physicians appropriate terminology and documentation needed to comply with CMS and other payor requirements.

Performs quality management activities as required and assists with other projects as assigned.

MINIMUM QUALIFICATIONS Education : High School diploma or equivalent. Experience : Two (2) years recent (within the last five (5) years) Hospital Inpatient acute care coding, Hospital Outpatient coding or Clinic Outpatient coding experience.

Passing score on the coding test administered during the interview process. Licensure / Certification / Registration : Must obtain the Certified Coding Specialist (CCS) certification within two (2) years of hire / transfer to the level III position.

Coding Technicians hired into the level III position prior to April 2009 are grandfathered with regard to the CCS certification requirement).

PREFERRED QUALIFICATIONS Education : N / A Experience : Three (3) years inpatient acute care plus outpatient coding experience.

Passing score on the coding test administered during the interview process. Licensure / Certification / Registration : Certified Coding Specialist (CCS) certification, or RHIT or RHIA.

KNOWLEDGE, SKILLS AND ABILITIES Extensive working knowledge of ICD-10 CM and coding systems. Knowledge of disease processes, procedures and pharmacology.

Ability to accurately assign ICD and CPT codes to inpatient and outpatient accounts. Understands and routinely uses compliant documentation standards.

Understands and is able to articulate knowledge of CMI, DRGs, APCs, CDI principles and billing and accounts receivable procedures.

Is able to discuss and negotiate CDI principles with CDI clinicians and physicians. Is able to provide coding consultation to groups of physicians and to other departments on request.

Ability to demonstrate attention to detail and aptitude for accuracy, understand and maintain the confidential nature of information required of the job, communicate effectively with others, including members of the medical staff.

Skill in using a medical dictionary, PDR, hospital formulary, as well as references such as Coding Clinic, Official Coding Guidelines and CPT Assistant.

READING - Intermediate : Ability to read and interpret documents such as operating and maintenance instructions and procedure manuals.

WRITING - Intermediate : Ability to write routine reports, correspondence, or procedures. REASONING ABILITY - Intermediate Skills : Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.

Ability to deal with problems involving several concrete variables in standardized situations. SPEAKING - Intermediate : Ability to effectively present information in one-on-one, small group situations or before groups of customers, clients, and other employees of the organization.

MATHEMATICAL SKILLS - Intermediate Skills : Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals and to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.

Ability to compute rate, ratio, and percent and to draw or interpret bar graphs to apply concepts of basic algebra and geometry.

PHYSICAL DEMANDS AND ENVIRONMENT PHYSICAL DEMANDS Moderate physical activity and to see, hear, speak, lift, sit for extended periods of times, bend and push Stand - Occasionally Under 1 / 3 (1-2.

5 hours) Walk - Occasionally Under 1 / 3 (1-2.5 hours) Sit - Continuously Over 2 / 3 (5.5 8 hours) Use hands to finger, handle, or feel - Continuously Over 2 / 3 (5.

5 8 hours) Reach with hands and arms - Occasionally Under 1 / 3 (1-2.5 hours) Stoop, Squat, Kneel, or Crouch - Occasionally Under 1 / 3 (1-2.

5 hours) Bending-repetitive forward - Occasionally Under 1 / 3 (1-2.5 hours) Talk or hear - Occasionally Under 1 / 3 (1-2.

5 hours) LIFTING REQUIREMENTS Up to 10 pounds - Occasionally Under 1 / 3 (1-2.5 hours) Up to 25 pounds - Rarely or None WORK ENVIRONMENT Typical Noise Level - Moderate noise (examples : business office with computers and printers, light traffic) WORKING CONDITIONS Typical office environment