HIM Professional Services Coder . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Under direct supervision, the Professional Services Coder is responsible for accurate coding of professional services (diagnoses, conditions, and procedures) from medical record documentation. Working from the appropriate documentation in the medical record, this person assigns codes and modifiers with ICD-9-CM, CPT, and HCPCS Level II codes when appropriate. All work is performed in accordance with the rules, regulations and coding conventions of ICD-9-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-9-CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD and our client's organizational and institutional coding guidelines. A Professional Services Coder I assigns codes for professional services rendered in the following settings: Hospital, Emergency Department (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV) and Medical Office. Major Responsibilities: Review Medical Records to resolve coding edits Under supervision, identify and resolve coding related edits by reviewing the medical record and ensuring that all data and codes are consistent with ICD-9-CM Official Guidelines, CPT, CPT Assistant, CMS, OMFS, Medical, and USDOL, as well as Regional and Local policies Correct data as appropriate Review Medical Records to identify diagnoses / procedures Under supervision, code all diagnostic and operative information from the medical record using ICD-9-CM, CPT, and HCPCS coding classification systems Specific Requirements (required unless noted otherwise): Ability to meet production and quality standards established for a Professional Services Coder II Demonstrated knowledge of Anatomy and Physiology, medical terminology, and disease processes Basic knowledge of reimbursement methodologies and conventions Knowledge of rules and guidelines for current coding classifications Ability to understand the clinical contents of a health record Demonstrated ability to communicate with physicians in order to clarify diagnoses and procedures coding and documentation requirements, including proper sequencing Must maintain current coding credential and perform associated Continuing Education Units Basic knowledge of hospital and/or physician clinic based revenue cycle Basic knowledge of professional services coding and billing in a multi-specialty environment Basic knowledge of government and other payer coding, billing and collection rules and regulations Completion of classes in medical terminology, anatomy and physiology, ICD-9-CM, CPT and HCPCS coding conventions, and disease process from and accredited program
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