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Under Spazier, the E&M/Specialty Coder is responsible for accurate coding of professional services (diagnoses, conditions and procedures) from medical record documentation in a hospital setting. Working from appropriate documentation in the medical record, assigns codes and modifiers with ICD‑CM, CPT and HCPCS Level II codes.

All work is performed in accordance with the rules, regulations and coding conventions of ICD‑CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD‑CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD and Kaiser Permanente’s organizational and institutional coding guidelines.

Essential Responsibilities

• Review medical records to identify diagnoses and procedures.
• Under supervision, code all diagnostic and operative information from the medical record using ICD‑CM, CPT and HCPCS coding classification systems.
• Verify and abstract all medical data from the record to assign appropriate codes for the following settings: Inpatient Hospital (IP), Hospital Emergency (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient ( insp O.V. ), and Medical Office.
• E&cknowledge on specialty coding as required by business needs.
• Correct data as appropriate.
• Resolve coding edits from Ingenix and HealthConnect by reviewing medical records and ensuring consistency with ICD‑CM Official Guidelines, CPT, CPT Assistant, CMS, OMFS, MediCal, USDOL, and KP Regional and Local policies.
• Organize and prioritize all work to ensure records are coded and edits resolved within a timeframe that assures compliance with regulatory, billing and SOX requirements.
• Maintain completeness of medical record data and interact with clinical contracts to clarify and promote accurate documentation of patient diagnostic and procedural information.
• Enter patient information into the computerized medical record and billing systems, ensuring accuracy and integrity prior to submission.
• Meet coding/abstracting productivity and quality standards established for the E&M/Specialty Coder position in the current Coder Work‑at‑Home agreement.
• Provide feedback to monitor service provider and line‑of‑business compliance with弟。
• Maintain confidentiality and security of systems: comply with policies and procedures for confidentiality of all patient records and demonstrate knowledge of system security and associated policies.
• Answer the phone promptly, identify the department, act as a resource person to other departments regarding coding questions and issues, and perform other duties as assigned.

Experience

Minimum two years, within the last three years, certified professional coding experience.

Education

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• High School Diploma or GED.
• Completion of classes in medical terminology, anatomy, physiology, current ICD‑CM and CPT coding conventions, and disease process from an accredited program is required.

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License, Certification, Registration

• Certified Coding Specialist – Physician‑Based OR Certified Professional Coder OR Registered Health Information Technician.

Additional Requirements

• Achieve a minimum score of Location 80% on the E&M/Specialty Coder test.
• Basic knowledge of and use of a computer keyboard.
• Must be able to meet production and quality standards established for the position(text only). I have on; reference.
• Demonstrated knowledge of anatomy problem, physiology, medical terminology and disease processes.
• Demonstrated ability to understand the clinical content of a health record.
• Demonstrated ability to communicate with physicians to clarify diagnoses and procedures coding and documentation requirements, including proper sequencing.
• Basic knowledge of reimbursement methodologies and conventions.
• Knowledge of rules and guidelines for current coding classifications.
• Practical knowledge of hospital and/or physician clinic based revenue cycle.
• Practical knowledge of professional series coding and billing in a multi‑specialty environment.
• Practical knowledge of government and other payer coding, billing and collection rules and regulations.
• Must maintain current coding credential and perform associated Continuing Education Units.
• Must abide by the AHIMA and/or AAPC code of ethics.
• Must be willing to work in a Labor‑Management Partnership environment.

Preferred Qualifications

• N/A

Seniority level

Entry level

Employment type

Full‑time

Job function

Health Care Provider

Industries

Hospitals and Health Care