Outpatient Coder I

Responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-10-CM, CPT and HCPCS or any other designated coding classification system in accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA. Abstracting required clinical information from the medical record.

Include the following. Others may be assigned.

• Coding:  Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Adheres to Standards of Ethical Coding (AHIMA). 
• Abstracting:  Reviews medical records to determine accurate required abstracting elements (facility/client specific elements) including appropriate discharge disposition.
• Coding Quality:  Demonstrates ability to achieve accuracy and consistency in the selection of principal and secondary diagnoses (including MCC & CC) and procedures.   Demonstrates ability to achieve accuracy and consistency in abstracting elements defined by per facility.
• Goal:   Average coding quality standard of =>95% accuracy per monitoring period.
• Does not meet =<95% accuracy
• Meets => 95% accuracy
• Exceeds =>95.01% accuracy

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Proficient in outpatient diagnosis coding guidelines     
• Ability to establish and maintain effective working relationships as required by the duties of the position
• Ability to concentrate and accomplish tasks with explicit accuracy
• Ability to use office equipment and automated systems/applications/software at an acceptable level of proficiency
• Functional knowledge of facility EMR, encoder and other support software