The Coder is responsible for accurately abstract selected data elements from each medical records for entry of coding into medical billing software. The Coder is responsible for coding reports in a timely manner. The Coder must have working knowledge of coding guidelines, demonstrates the ability to work in a fast-paced coding environment, possess basic knowledge of revenue cycle and understands the role of financial reports used to manage un-coded accounts. The Coder may be cross trained in other functions of the revenue cycle, such as charge entry.

Responsibilities:

· Assigns ICD-10-CM and CPT-4 codes according to the Official Guidelines for coding and reporting.

{Including but not limited to AHA, AMA, AHIMA, CMS, NCHS, and MLHS specific guidelines).

• Adheres to HIM policies regarding diagnosis and procedure code assignment and abstraction.
• Accurately abstracts selected data elements from each record into the clinical management system to ensure the accuracy of various ASC databases.
• Informs management of any issues or concerns regarding documentation in the medical record.
• Collaborates with coding clerk and/or supervisor to ensure all cases are coded within timeframes specified in guidelines.
• Maintains a coding compliance score of 92% to 95%.
• Maintains established productivity standards.
• Attends mandatory educational sessions and earns 10 continuing education credits per calendar year.
• Refers all coding/billing inquiries from internal or external sources to other coders for peer-review.
• Retrieves medical records to be coded and abstracted in an accurate and timely manner to ensure daily entry of charges by the billing team.
• Must be willing to attend seminars for education in coding and billing.
• Must be willing to attend software training to keep up with advances in information technology.

Qualifications & Experience:

• Minimum of two years Multi-Specialty Ambulatory Surgery Center experience is required.
• AAPC CPC Ce r tification, requ i red.
• Experience using a medical billing software. Must be familiar with Windows & MS Office.
• Minimum of 2 years experience coding ICD-10-CM, CPT-4, and DRG and/or APC assignment required
• High school graduate or equivalent.
• Completion of basic coding courses from AHIMA accredited program.