Thedacare-posted 3 months ago
Part-time
Appleton, WI

The Coder (Hospital - II) reviews patient medical record documentation and assigns and sequences ICD-10-CM diagnosis codes and ICD-10-PCS or CPT/HCPCS procedure codes, when applicable, to inpatient, observation, and/or outpatient surgical accounts, abiding by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with official coding guidelines and other regulatory requirements. Communicates with providers when needed to obtain complete and specific documentation to accurately assign codes. Follows up and obtains clarification on charge issues. Works with providers and/or clinical documentation improvement (CDI) specialists to achieve a high level of documentation specificity. Maintains department standards for timely coding completion.

  • Reviews patient medical records for inpatient, observation, and/or outpatient surgical accounts.
  • Assigns ICD-10-CM diagnosis codes and ICD-10-PCS or CPT/HCPCS procedure codes, when applicable, to all accounts, and sequences as outlined in the ICD Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS), CPT/HCPCS Guidelines, and other regulatory requirements.
  • Communicates with providers and other clinical team members to obtain additional information, diagnoses specificity, or completion needed to accurately assign codes.
  • Manages follow up work queues to ensure timely coding completion.
  • High School diploma or GED preferred
  • Must be 18 years of age
  • One year of hospital coding experience.
  • Diploma/certificate in coding: CCS (Certified Coding Specialist, (AHIMA), or COC (Certified Outpatient Coder), (AAPC), or CIC (Certified Inpatient Coder), (AAPC) Or: RHIT (Registered Health Information Technologist) (AHIMA)
  • Lifestyle Engagement e.g. health coaches, relaxation rooms, health focused apps (Wonder, Ripple), mental health support
  • Access & Affordability e.g. minimal or zero copays, team member cost sharing premiums, daycare
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