MEDICAL RECORDS CODER II

Performs evaluation and review of medical record documentation t o accurately assign codes for the primary/secondary diagnoses and proced ures using ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II. 

S equence the diagnoses and procedures using coding guidelines and ensures DRG or APC assignment is accurate. 

HIM Coder Tech II focusestheir work on capturing data with consideration for regulations and req uirements to support medical necessity and reimbursement. 

Duties and Responsibilities of this Level:

Re view medical record documentation and accurately assign codes for the pr imary/secondary diagnoses and procedures using ICD-10-CM, CPT-4 and HCPC S Level II.  Sequence diagnoses and procedures using coding guidelines.  54 % of time spent</s pan>

Maintain competency in ICD-10-CM, CPT-4 and HCPCS Lev el II and knowledge of reimbursement reporting requirements. 95% Minimum quality.

Maintain a thorough understanding of anat omy and physiology, medical terminology, pharmacology, disease processes and surgical techniques through participation in continuing education p rograms to effectively apply ICD-10-CM coding guidelines for assignment of outpatient diagnoses and CPT-4 and HCPCS Level II for procedures. </s pan>

Knowledge coding and charging requirements to ensure accurate code submission along with management of edits and denials. Pro cessing claim edits. 4% of time spent

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Researching and processing denied claims to correct and resu bmit. 5% of time spent

 

Pro cessing IP conversions from IP status to Observation can be up to 20% of time spent.

  Knowledge of UHDDS definitions and data requirements to support accurate coding and data collection. Assignment/validation of correct discharge disposition based on UHDDS guidelines. 2% of tim e spent

Knowledge of NCD/LCD edits to support compliance with medical necessity requirements.

< span>Apply knowledge of all coding reference materials and education to problem solve unique or new cases resulting in the assignment of appropr iate diagnosis and procedure codes. Validation of applicabl e hard coded CPT codes.  5% of time spent</s trong>

 

Use logi c and reasoning to demonstrate critical thinking in the assignment of di agnosis and procedure codes with consideration for reimbursement, qualit y and other data capture requirements. 5% of time spent</ strong>

 

Recommend cases that need to be queried of the physicians when code assignments are not stra ightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. 5% of time spent.</ span>

 

 

Mainta in compliance with quality and quantity standards as outlined in Hospita l Coding Policies.

Abide by the Standards of Ethica l Coding as set forth by the American Health Information Management   As sociation and adheres to official coding guidelines.

 

Perform other relatedduties incidental to the wor k described herein