Job Description

The Coder I is responsible for performing International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding for primary care billing, case mix, and data collection purposes. The Coder I performs reviews of patient charts and validates coding for accuracy and capture of all billable charges. The Coder I maintains data integrity within the hospital information systems.



Assigns ICD and CPT codes to patient diagnoses and procedures for primary care services + Assess the accuracy and completeness of all information provided in documentation
+ Assign codes for procedures, services, and diagnosis by following set classification systems
+ Identify chargeable services/items for emergency and ancillary visits and ensure that all charges are accurately billed into the system
+ Code and post procedures and accurately assign CPT and ICD codes to them
+ Prioritizes assignments according to established criteria and decrease pending accounts
+ Contacts or queries physician when additional information or clarification is needed to code
Reviews documentation and coding for accuracy and practices compliance with coding guidelines and protocols + Validates documentation and ICD/CPT codes and modifiers
+ Performs compliance edits on outpatient records, and ensures discrepancies are resolved
+ Reviews abstracted and statistical data for corrections and submits findings to leader
+ Maintains current information/knowledge regarding coding principles and guidelines
Utilizes the Electronic Health Record system and other related computer systems and software + Selects appropriate assignments for coding/abstracting from work queues
+ Enters coded and abstracted data appropriately for use within the hospital information system
+ Maintains data integrity through review of the overall completeness, accuracy, and consistency of data within relevant systems


Education:


High School or GED
Experience:


1 year performing clerical work or data entry
Skills:


Organizing and interpreting technical data Multitasking, time-management, and organization * Verbal and written communication