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Job Description

HIM Coding Tech I
Date: 09/21/2009
Location: Hazel Crest, IL
Facility:SOUTH SUBURBAN HOSPITAL
HIM Coding Tech I - 27628
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Attention to detail (such as interpretation of clinical data including medical terminology and disease processes).
Analytical skills for abstracting of clinical data.
Ability to interpret regulatory and payer rules and directives concerning coding.
Computer experience.
Certified Coding Specialist (CCS) credential for inpatient or outpatient coding positions or Certified Coding Specialist-Physician based (CCS-P) for outpatient coding positions.
Completion of coding certificate program from recognized community college (typically 20 semester hours of college credit courses) or significant coding experience prior to earning CCS or CCS-P credential.
--OR
Recent HIM degree graduate who is required to earn RHIT or RHIA credential within one year of hire.
--AND--
Prefer 2-3 years of recent acute care hospital coding experience.
Achieve satisfactory score on Advocate s coding test.

CCS or CCS-P credential or RHIT/RHIA eligible.

Job Description:

This is a mid-level coding position for an individual with coding education and experience consistent with the job qualifications. Performs outpatient and a limited number of inpatient coding function on a select group of patient types under supervision of coding supervisor. Reviews medical record documentation to ensure the complete coding of all-relevant diagnoses and procedures for hospital billing. Assigns and sequences ICD-9-CM diagnoses and ICD-9-CM and CPT procedures in accordance with advice from Coding Clinic and ICD-9-CM Official Coding Guidelines and CPT Assistant (CPT/HCPCS) guidelines. Uses 3M coding products including encoder and groupers for Diagnosis Related Groups (DRG) and Ambulatory Payment Class (APC) for Medicare reimbursement and other third-party payers and for internal Advocate business/quality purposes. Abstracts selected demographic and clinical information to create a comprehensive database of information for billing purposes and internal data management. As the Coding Technician I gains knowledge, skills and the appropriate additional education and certification, the Coding Technician I may progress in the types of coding assignments given and will require less supervision of the tasks identified in the job accountabilities and may have the opportunity to be promoted to higher coding positions.
Accountabilities:
1. Code all diagnoses and procedures according to the current International Classification of Disease, Clinical Modification (ICD-9-CM) and Physician s Current Procedural Terminology, current edition (CPT/HCPCS) rules and principles and coding guidelines utilizing a computerized encoding system. Coder may perform any of all of the following types of coding in order of priority: I. Non-Medicare/Medicaid inpatient records II. Same Day Surgery records including outpatient surgical procedures, GI laboratory procedures, GI laboratory procedures, cardiac and other therapeutic procedures including records that require Ambulatory Payment Classification (APC) assignment for Medicare outpatient reimbursement. III. Emergency Department visits and related procedures including records that require Ambulatory Payment Classification (APC) assignment. IV. Outpatient diagnostic records, including results of radiology, laboratory, cardiology, neurology and other tests V. Outpatient therapeutic records including physical medicine, cardiac and pulmonary rehabilitation and other services VI. Clinic records that describe physician and other health care professionals evaluation and management of patients. VII. Physician orders received in Registration/Access or Central Scheduling Departments for the purpose of medical necessity determination related to Medicare s Local Medical Review Policies as needed to determine if an advance beneficiary notice should be issued.
2. Contacts physicians and other health care professionals and hospital department representatives to obtain diagnosis information required for coding and billing of outpatient services.
3. Abstracts select data elements in accordance with established policies to create a complete and comprehensive database of patient visits
4. Maintains current knowledge of ICD-CM and CPT/HCPCS coding systems, as well as APCs and other outpatient reimbursement methodologies and maintains coding credential certification and maintains HIM and/or coding certification credential with AHIMA
5. Contribute toward achieving the team goals for the Clinical Data Section
6. Performance of other duties
Addendum:
ADDENDUM TO JOB DESCRIPTIONS RELATED TO PATIENT SAFETY Report patient safety events and near misses in timely fashion Adhere to all behavioral and procedural patient safety practices Promote culture of safety through identifying threats to patient safety and intervening to prevent patient harm Communicate openly and promote team work Report intimidating behavior and other threats to patient safety promptly
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