Job Description

JOB SUMMARY

The Coding Technician II is primarily responsible for the accurate assignment of diagnosis and procedure codes following

established coding guidelines and abstracting appropriate data for reporting from inpatient, day surgery, and observation

accounts. This position supports the activities of the Revenue Cycle Management (RCM) Department.

PRIMARY DUTIES AND RESPONSIBILITIES

– Reviews documentation in the electronic medical record (EMR) of inpatient (IP), day surgery (SDS), and

observation (OBS) accounts and applies the appropriate guidelines for assignment of diagnosis and procedure

codes.

– Appropriately applies AHA Official Coding Guidelines and HAAD Coding Guidelines for coding of inpatient and

outpatient accounts.

– Assigns the correct ICD-9-CM/ICD-10-CM principal diagnosis code for inpatient and observation accounts and pre-

operative/post-operative diagnoses for SDS accounts.

– Identifies comorbid conditions documented by the physician and assigns the appropriate ICD-9-CM/ICD-10-CM

diagnosis codes for the condition.

– Assigns the appropriate Current Procedural Terminology (CPT) principal procedure code(s) for day surgery,

observation, and inpatient accounts.

– Reviews documentation in the EMR and assigns the appropriate Evaluation and Management (E&M) code for

physician services performed in the inpatient and observation units.

– Correctly groups the IR-DRG of inpatient discharges.

– Abstracts required demographic, statistical, and medical information from each patient record.

– Maintains established productivity measures for the coding of inpatient, day surgery, and observation accounts.

– Coordinates with Patient Access Services (PAS), Patient Financial Service (PFS), and Case Management to

provide appropriate diagnosis and procedure codes and grouped IR-DRGs for obtaining authorizations of

healthcare services from contracted insurance companies.

– Appropriately queries the clinician when documentation is incomplete or ambiguous.

– Identifies both electronic and hard copy reference materials appropriately and efficiently to facilitate the accuracy,

consistency and specificity of code assignment.

– Coordinates with the Clinical Documentation Specialist (CDS) on issues related to documentation.

– Maintains confidentiality of the patient’s confidential health information (CHI) in both electronic and paper formats.

– Participates in the development of internal education programs by identifying key areas for improvement in

documentation for appropriate code assignment and maintains a record of all programs

– Performs other duties and participates in special projects as assigned by the HIMS Management team.

EXPERIENCE REQUIREMENTS

– Minimum 3 years’ experience in a Health Information Management (HIMS) or Medical Records Department

preferred.

– Minimum 2 years’ experience in clinical coding.

– Experience utilizing health information systems (HIS) software preferred.

– Knowledge of Microsoft Excel and Microsoft Word.

– Good verbal and written English language skills.

EDUCATION REQUIREMENTS

– Minimum Associates of Science in Health Information Technology or Healthcare Management.

– Graduate of a recognized clinical coding program preferred.

– Certified Coding Specialist (CCS) credential preferred but Certified Coding Associate (CCA) will be considered with

requisite experience.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

– Work is performed in a typical office environment.

– Overtime and/or weekend hours may be required to meet deadlines.

– Requires the ability to work under pressure to meet deadlines.

– Sitting for approximately 4-6 hours per day.

– Sufficient mobility to visit other departments within the CCAD campus.

– Light to moderate work with 10 kilograms maximum weight to lift and carry.

– Normal or corrected vision and hearing.

ORGANIZATION-WIDE COMPETENCY ASSESSMENT REQUIREMENTS

All employees will embrace the CCAD mission, vision and values and be responsible for adhering to the core values of the institution,

including: Patient’s First, Collaboration, Mutual Respect, Quality, Patient Safety, Integrity, Cultural Sensitivity and Compassion.

All employees are also expected to meet the standards of performance outlined in the Organization-Wide Competencies listed below as

applied to the position.

Customer Service Orientation includes attitude, behavior, interpersonal skill and problem solving that enable an employee to respond to

internal and external customer needs and expectations in a positive manner. Adaptability including teamwork, flexibility needed to fulfill job

responsibilities, adapting to changes in work environment and accepting supervisory feedback. Efficiency and Effectiveness includes

quantity and quality of desired work, as well as organization skills necessary to perform successfully. Essential Job Requirements

includes adherence to all relevant policies, procedures and guidelines affecting the work environment, as well as maintenance of required

competencies and communication skills. Managerial Responsibilities includes overall accountability for assigned work group relative to

operational goals, personnel requirements and budgetary constraints