HIM Coder - TMCOne Quality - Tucson Medical Center

SUMMARY:

Provides timely and accurate administrative and clinical data through the accurate assignment of ICD-9-CM and CPT codes while complying with the regulations and requirements of the Federal Government, State licensing agencies and the hospitals policies and procedures. Supports TMCHs management planning process and ensures appropriate reimbursement for inpatient and outpatient services.

ESSENTIAL FUNCTIONS:

Assigns the correct ICD-9-CM and CPT code to each diagnosis and operative procedure substantiated by documentation contained in the medical record.

Follows departmental and official ICD-9-CM and CPT coding guidelines to ensure consistent and accurate coding of diagnostic and procedural data.

Utilizes the 3M HDM System, Epic, and any other necessary applications for proper coding, ensuring accuracy.

Ensures that the medical staff documents have sufficient information for accurate coding and appropriate reimbursement by utilizing clarification forms when necessary.

Assists physicians, their office staff, quality management and other hospital personnel with coding and DRG/APC questions.

Determines the sequence of diagnoses according to uniform hospital discharge data.

Inputs abstract data and codes into computer to gather administrative and clinical data for distribution to outside regulatory agencies, third party payers, administrative staff and physicians.

Requests clarification of diagnoses from physicians when not recorded on discharge or if information is incomplete.

Ensures that institutional policies and procedures for maintenance of medical records are followed; conducts periodic audits of medical records to ensure compliance with standards.

Receives requests; may access operative diagnostic indices and printouts to retrieve medical records and record information in specific diagnostic categories.

Monitors the exception accounts reports and corrects edits in conjunction with the patient accounts staff to ensure timely billing of accounts and resolution of potential errors.

Maintains current knowledge of coding principles and guidelines as coding conventions are updated.

Maintains a 96% coding accuracy rate.

Operates a personal computer, calculator, FAX machine, copy machine or related office machinery in performing assigned duties.

Operates word processing equipment to store, edit, format, print and revise letters, memos, statistical tables, reports, forms, labels, and other printed materials.

Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION: Completion of a2-year college or technical school curriculum in Health Information Management, or an equivalent combination of relevant education and experience. Preferred is the completion of a 4-year college curriculum in Health Information Management.

EXPERIENCE:One (1) year of related medical coding experience in an acute care hospital setting.

LICENSURE OR CERTIFICATION: Requires one or more of the following: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Certified Professional Coder (CPC2), or Certified Professional Coder-Hospital (CPC-H).

KNOWLEDGE, SKILLS AND ABILITIES:

Knowledge of ICD-9-CM, CPT, UHDDS sequencing, and DRG and outpatient reimbursement schemes.

Knowledge of medical terminology.

Skill in the coding of medical information and maintaining databases to ensure accuracy.

Skill in analyzing workflow and determining importance of position.

Skill in organizing tasks to ensure the timely and accurate coding of information.

Skill in both oral and written communication.

Ability to read, analyze and interpret professional journals, governmental regulations, and coding

guidelines.

Ability to follow written and verbal instructions.

Ability to review work and pay attention to detail to ensure the utmost accuracy of the coding work being

performed.

Ability to maintain good working relationships and communication with the medical staff, nursing, administration, and other ancillary departments with the hospital.

Ability to perform multiple tasks and ensure completion to meet strict deadlines.