Health Information Coder I/II -FULL BENEFITS

DEPARTMENT: Health Information Management

 

SCHEDULE: Full-Time regular, 20 hours per week, Day shift. Monday through Friday: 8:00am to 12:00pm.

 

EDUCATION: HS Diploma or GED. Completion of classes in medical terminology, anatomy and physiology,

ICD-9 and Current Procedural Terminology (CPT) coding conventions, and disease process from an

accredited program. Basic PC skills.

 

LICENSE/CERTIFICATION: Certified Coding Associate (CCA) and eligibility to become a Certified Coding

Specialist (CCS), or Registered Health Information Technician (RHIT), or Registered Health

Information Administrator (RHIA).

 

JOB SUMMARY: Under indirect supervision, is responsible for accurate coding of all inpatient, and

outpatient services, procedures, diagnoses and conditions, working from the appropriate

documentation in the medical record. Classification systems include ICD-9-CM, CPT, Healthcare Common

Procedure Coding System (HCPCS) as well as other specialty systems as required by diagnostic

category. All work is carried out in accordance with the rules, regulations and coding conventions

of the American Hospital Association (Coding Clinic), ICD9, Centers for Medicare and Medicaid

Services (CMS), Office of Statewide Health Planning and Development (OSHPD), and Kaiser

organizational/institutional coding guidelines.

 

As needed, Coders II may assist and be a resource for data integrity for other employees who need

clarification and assistance in coding.

 

Positions assigned to this classification are differentiated from those assigned to the Hospital

Coder I classification in that only the former are typically characterized by the performance of a

higher, more complex and responsible level of work generally associated with - but not limited to -

the coding of in-patient Medicare medical records/data. Coder II also differs from Coder I in the

type and amount of supervision received; responsibility for data comprehensiveness and quality

assurance; direction provided to other staff; data analysis, knowledge of procedures related to the

sequencing of diagnoses and interventions, as well as data management policies and procedures;

required quantity and quality performance standards.

 

QUALIFICATIONS: Must have at least three (3) years hospital inpatient experience coding within the

last five years. Demonstrated ability to understand the clinical content of a health record,

including the most complicated records. Must also be able to communicate with physicians in order to

clarify diagnoses/procedures and sequencing of diagnoses. Ability to demonstrate knowledge of and

utilize auditing skills related to coding quality and compliance. Must be able to meet quantity and

quality standards established for Coder II. Must maintain a minimum of ten (10) CE units annually.

Must maintain current coding credential. Will abide by the American Health Information Management

Association coding code of ethics.

 

Must be able to work in a Labor/Management Partnership.

 

PREFERRED QUALIFICATIONS: Background knowledge analysis, assembly, terminal digit filing, and

physician's incomplete processing experience preferred.

 

SKILLS TESTING: Basic PC skills. Minimum of 35 words per minute. Must be able to pass Kaiser coding

test at 75 %.

 

DUTIES:

 

Review medical records to identify diagnoses/procedures. Independently organizes and prioritizes all

work to ensure that records are coded in timeframes that will assure compliance with regulatory

requirements. Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning

the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM, CPT,

Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification

systems. Demonstrates knowledge of anatomy and physiology to interpret general medical

classifications for coding discharge data including the most complicated encounters/cases.

 

Assigns Codes. Codes all diagnostic and operative information from the medical record using

ICD-9-CM, CPT and HCPCS coding classification systems and independently quality checks own work.

Selects the Diagnosis Related Group (DRG) for each inpatient case. Optimizes hospital payment

legitimately and ethically by utilizing approved coding guidelines and conventions. Reviews DRG

discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.

Verifies and abstracts, all medical data from the record to complete a data abstract on each

hospital encounter. Corrects data as appropriate.

 

Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, OSHPD and CMS,

regional and local policy.

 

Other Duties:

 

Answers the telephone promptly and identifies themselves and the department.

 

Acts as an expert resource person to other coders and personnel in other hospital departments

regarding coding questions and issues.

 

Other duties as assigned by supervisors.

 

Supervisory Responsibilities

 

This job has no supervisory responsibilities.

 

Compliance Accountability

 

Consistently supports compliance and the Principles of Responsibility (KP's code of conduct) by

maintaining confidentiality, protecting the assets of the organization, acting with ethics and

integrity, reporting non-compliance, and adhering to applicable Federal and State laws and

regulations, accreditation and licensure requirements, and KP policies and procedures.