The HIM Medical Records Coder II utilizes experience, education, coding guidelines and Duke coding policies and procedures to perform all daily duties. Performs evaluation and review of medical record documentation to accurately assign codes for the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II. Sequence the diagnoses and procedures using coding guidelines and ensures DRG or APC assignment is accurate. The HIM Coder Tech II focuses their work on capturing data with consideration for regulations and requirements to support medical necessity and reimbursement.
Duties and Responsibilities:
Review medical record documentation and accurately assign codes for the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II. Sequence diagnoses and procedures using coding guidelines.
Maintain competency in ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II and knowledge of reimbursement reporting requirements. Maintain a thorough understanding of anatomy and physiology, medical terminology, pharmacology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM coding guidelines for assignment of outpatient diagnoses and CPT-4 and HCPCS Level II for procedures. Knowledge coding and charging requirements to ensure accurate code submission along with management of edits and denials.
Knowledge of UHDDS definitions and data requirements to support accurate coding and data collection. Knowledge of NCD/LCD edits to support compliance with medical necessity requirements. Apply knowledge of all coding reference materials and education to problem solve unique or new cases resulting in the assignment of appropriate diagnosis and procedure codes.
Use logic and reasoning to demonstrate critical thinking in the assignment of diagnosis and procedure codes with consideration for reimbursement, quality and other data capture requirements.
Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
Maintain compliance with quality and quantity standards as outlined in DUHS HIM Coding Policies. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
Perform other related duties incidental to the work described herein.
High school diploma required.
2 or more years of coding experience is strongly preferred.
Degrees, Licensures, Certifications Requirements:
Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS)
Knowledge, Skills, and Abilities:
Understand and apply appropriate Centers for Medicare and Medicaid Services (CMS) coding guidelines
Knowledge of denial management processes
Basic ICD-10-CM and PCS coding conventions