Coder II | UF Heart & Vascular (Jax) | Full-time | Days (REMOTE)

UF Health • Jacksonville, FL

87d • Remote

About The Position

The Coder II position assigns diagnoses and procedure codes to Observation and Same Day Surgery medical records.

Requirements

• High School Diploma/Equivalent
• 1-year Medical Record Coding
• Any AAPC or AHIMA Medical Coding Certification

Nice To Haves

• Graduate of a Health Information Management Program

Responsibilities

• Assigns correct ICD-10-CM code to all diagnoses and correct CPT code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical record in order to retrieve proper documents (i.e. discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity.
• Reads and understands operative reports in order to classify to most accurate CPT codes.
• Researches complex operations as necessary.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Assigns correct modifier on CPT codes that are required under the Medicare APC reimbursement.
• Maintains a thorough knowledge of the use of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies.
• Maintains a positive working relationship with physicians in order to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains a thorough knowledge of the prospective payment system and any new codes or DRG's added/changed each year.
• Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as the ICD-9-CM coding conventions, Coding Clinic, and other official resources to substantiate the most appropriate, correct code assignment.
• Stays abreast of Medicare's medical review policies and incorporates updates and changes into the coding process.

What This Job Offers

• Industry: Ambulatory Health Care Services
• Education Level: High school or GED