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Job Description Summary

Under experienced leadership the Professional Surgical Coder is an advanced coding position that is responsible for accurate and timely assignment of codes to diagnoses and procedures for all outpatient and inpatient diagnostic and procedural coding. Using established department policies and procedures in conjunction with the current versions of ICD-9 and CPT-4, the Professional Surgical Coder will determine the proper diagnosis, assign co-morbidities and complications, secondary diagnoses and any HAC (Hospital Acquired conditions) documented. As well as both E/M codes and procedure codes. The Professional Surgical Coder is expected at South Shore Physician Ambulatory Enterprise to query providers when documentation requires clarification and he/she proactively works with medical leadership to address concerning documentation trends. The Professional Surgical Coder works with direct support from and under the direction of the Billing and Coding Manager to make certain their skills and knowledge remain in peak condition.

Job Description

ESSENTIAL FUNCTIONS

1 - Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures performed.  Assigns proper ICD-9CM / ICD10CM and CPT-4 diagnostic and procedural codes to charts and related records by reference to designated coding manuals and other reference material.
   a - Codes ________ (# determined according to type of record coded) records per hour, consistently with 95% accuracy.
   b - Assigns diagnostic and procedural codes for physicians in the inpatient, outpatient, and observation setting. 

2 - Identifies any and/or all complications or comorbidities.
   a - Applies sequencing guidelines based on medical record information provided according to official coding rules

3 - Assesses the appropriateness of medical record documentation to ensure that it supports the procedure(s), diagnosis', as well as complications and/or comorbid conditions documented.  Consults with the appropriate provider to clarify medical record information.
   a - Identifies any documentation inadequacies with provider and clarifies medical record information with courtesy and tact.
   b - Retrieves any and all records corresponding to surgical cases, alphabetizes and reviews corresponding laboratory reports to ensure accurate assignment of ICD-9-CM and CPT-4 codes.
   c - Verifies all surgeries and documentation is accounted for
   d - Verifies that the coded information is entered into the billing company within 5 days of receipt without any errors.  

4 - Answers provider/clinician questions regarding coding principles, 
   a -  Assists billing company with any and all coding queries for claims appeals and resolution. 
   b - Answer all other ancillary departments with coding questions in a timely and courteous manner

5 - Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature and so forth.
   a - Utilizes professional affiliations, etc., in order to maintain current in professional developments.
   b - Attends all pertinent coding seminars.
   c - Maintains updated coding books and all electronic resources available

6 - Works collaboratively with appropriate team members to recommend strategies for process improvement

7 - Assists in responses to billing audit request from outside the institution

8 - Abides by Standards of Ethical Coding as set forth by American Health Information Management Association (AHIMA) 

9 - Meets coding, quality and productivity standards.

10 - Performs all job functions in compliance with applicable federal, state and local laws as well as hospital policy and procedures
 

JOB REQUIREMENTS

Minimum Education - Preferred

Equivalent to an Associate's Degree in Medical Information Technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD-9-CM coding and prospective payment) preferred.

Minimum Work Experience

Two to three (2-3) years in a surgical practice preferred.

Required additional Knowledge and Abilities

CCS or CCS-P or CPC or CPC-H - Certified Coding Specialist OR Certified Coding Specialist- Physician Based OR Certified Professional Coder OR Certified Professional Coder - Hospital preferred.

Strong proficient computer and data entry skills to gather and interpret data.

Strong analytical skills to gather and interpret data.