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The Coding Technician I is primarily responsible for the accurate assignment of diagnosis and procedure codes following established coding guidelines and abstracting appropriate data for reporting outpatient, Emergency Room, and ancillary services accounts. This position supports the activities of the Revenue Management Department.
PRIMARY DUTIES & RESPONSIBILITIES
- Applies the appropriate coding guidelines for assignment of the primary diagnosis and co-morbidities for outpatient accounts.
- Applies the appropriate guidelines for assignment of primary and secondary procedures.
- Assigns the appropriate ICD-10-CM code for the primary diagnosis on 95% of accounts audited.
- Assigns the appropriate CPT codes for procedures on 95% of accounts audited.
- Assigns the appropriate Evaluation & Management code on 95% of accounts audited.
- Abstracts required demographic and statistical data from each patient record on 95% of accounts audited.
- Demonstrates knowledge of the content of the electronic medical record for both inpatient and outpatient accounts.
- Demonstrates knowledge of the physician query process and appropriately queries when documentation is incomplete or ambiguous.
- Demonstrates appropriate analysis of electronic medical record documentation for completeness, accuracy, and timeliness.
- Maintains an average productivity rate of 130 accounts coded per day.
- Identifies both electronic and hard copy reference materials appropriately and efficiently to facilitate the accuracy, consistency and specificity of code assignment.
- Coordinates with the Clinical Coding Support Specialist on issues related to documentation.
- Maintains confidentiality of patient’s protected health information (PHI) in both electronic and paper formats.
- Participates in continuing education programs and maintains a record of continuing education programs attended.
- Performs other duties and participates in special projects as assigned by the HIMS Management team.
- Minimum 2 years experience in a Health Information Management (HIMS) Department or Medical Records Department preferred.
- Minimum 2 years experience utilizing health information systems (HIS) software or equivalent experience preferred.
- Familiarity with a coding and abstracting system preferred.
- Good verbal and written English language skills.
- Minimum Associates of Science degree in Health Information Technology or healthcare related field preferred.
- Graduate of a recognized clinical coding technician program or equivalent.
- Certified Coding Associate (CCA) or Certified Procedural Coder (CPC) credential preferred
ORGANIZATION-WIDE COMPETENCY ASSESSMENT REQUIREMENTS
All employees will embrace the CCAD mission, vision and values and be responsible for adhering to the core values of the institution, including: Patient’s First, Collaboration, Mutual Respect, Quality, Patient Safety, Integrity, Cultural Sensitivity and Compassion.
All employees are also expected to meet the standards of performance outlined in the Organization-Wide Competencies listed below as applied to the position