Outpatient Medical Coder 2

Scope of Position

Coding services assigns diagnosis and procedural codes to hospital outpatient medical records to facilitate the reimbursement and data collection for the individual business units of the OSU Health System.

ICD-10-CM/CPT diagnoses and procedure codes are applied to all outpatients treated within the OSU Health System that are not captured through the charge description master. Medical record abstract data is assigned based on information reviewed for accuracy in IHIS during the coding process.

Position Summary

The position is responsible for coding medical records and other documents at the conclusion of the patients visit. A senior medical records coding specialist requires the skill set to code multiple work types for outpatient services including: surgery, emergency department, clinics including oncology, and observation. This requires the selection of appropriate admitting diagnosis, principal and secondary diagnoses, principal procedure, and secondary procedures; assigning accurate ICD-10 and/or CPT-4 codes; sequencing the diagnoses and procedures codes; and abstracting information including admission source, type, disposition, admitting, attending and procedure attending physicians.

Codes are selected in the Computer Assisted Coding/Encoder Software following review of information in the electronic medical record system, IHIS. Information abstracted and coded is interfaced to IHIS Resolute Billing system. This staff member is responsible to address all edits or denials during the coding and abstracting process for complete and accurate coding for hospital reimbursement.

This staff member will maintain productivity and quality standards set for the department maintain an approved work schedule and submit a weekly volume log.

Minimum Qualifications for hire or promotion

For Hire:

• Minimum completion of a CAHIIM-approved coding certificate program or HIMT program.

• Demonstrated coding proficiency through satisfactory completion of OSUWMCs coding test.

• Familiarity or experience with computer-assisted coding and/or automated encoder.

• Minimum of 1-year outpatient coding experience (ICD10-CM and CPT) for service types such as emergency, outpatient, ambulatory surgery, observation, and series/clinics.For promotion: The ability to code at least four outpatient service types (ASU, observation, emergency, outpatient, and series/clinics).

Required:

• Required for hospital coding: Credentialed as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) by the American Health Information Management Association; or Certified Outpatient Coder (COC), formerly CPC-H, by AAPC.

Radiation Oncology Certified Coder by AMAC (note: applicable if only coding Radiation Oncology accounts).

Competency expectations:

• Maintain continuing education requirements as determined by the American Health Information Management Association or American Academy of Professional Coders. Review Coding Clinics, CPT assistant as frequently as needed for education purposes, and to ensure the official coding guidelines are followed.

• The medical records coding specialist attends coding meetings and coding education sessions for updates on coding guidelines and related education opportunities.