Requires knowledge of and skill in applying International Classification of Diseases and Procedures (ICD), and Current Procedural Terminology (CPT) code sets and associated Medicare/Medicaid rules and guidelines. Reviews and interprets patient medical record documentation to identify pertinent diagnoses and procedures and assigns ICD-10-CM and CPT 4 codes accurately and timely to the highest level of specificity based upon physician documentation for ambulatory surgery, special procedure, observation, emergency department, outpatient ancillary and clinic visit records. Primarily codes a mixture of different types of Evaluation & Management medical records and assists with coding outpatient ancillary clinic, specialty clinic, surgical and emergency room record coding as necessary. Communicates with physicians and other providers regarding documentation requirements and collaborates with different departments on an as needed basis. Maintains current knowledge of coding and documentation changes, rules and guidelines.
Education & Experience
CCS or CPC with (1) year minimum current and continuous full-time ICD-10-CM & CPT-4 evaluation & management coding.
Knowledge of medical terminology, anatomy and physiology and the disease process.
Ability to work well independently and productively with minimal guidance and supervision.
Detail-oriented, organized and flexible with exceptional interpersonal and communication skills.
Demonstrates coding skills and critical thinking skills utilizing current policies and procedures.
RHIA or RHIT.
Knowledge of health insurance processing.
Skilled with electronic medical record applications, automated encoders, and other software applications.