Outpatient Coder

Job Purpose

This position is for an outpatient coder with Emergency Department and ambulatory surgery coding experience. The coder will code surgery, emergency department, and ancillary records. Emergency Department coding includes injection and infusion coding as well as assignment of the E&M professional fee.

The role is responsible for abstracting and coding accounts accurately, completely, and compliantly to support timely reimbursement and reporting. The coder verifies, reviews, analyzes, and abstracts medical information; researches missing clinical information; assigns accurate codes; queries physicians when required; elevates documentation issues to management; ensures valid orders are present before coding; and communicates daily with the Coding Manager regarding obstacles that prevent a chart from being coded.

Essential Functions

• Maintain a 95% or higher accuracy rate as validated by audit.
• Code at established productivity standards for ED, outpatient surgery, observation, and outpatient diagnostic accounts.
• Ensure valid physician or provider orders are present for outpatient surgery, observation, and diagnostic accounts.
• Query physicians to clarify missing, ambiguous, incomplete, or conflicting documentation.
• Abstract information from the medical record into the abstracting module.
• Post charges for injection and other procedure coding as required.
• Escalate missing or noncompliant orders and documentation issues to management.
• Demonstrate proficiency with PC and software systems used by Coding and HIM staff.
• Manage time and workload with attention to accuracy, timeliness, and deadlines.
• Stay current with coding updates through Coding Clinics and CPT Assistants.
• Complete required formal and informal education annually.
• Perform additional responsibilities as directed.

Behavioral Standards

• Exhibit positive customer service in daily work interactions.
• Maintain a courteous and respectful attitude toward internal and external customers.
• Communicate accurately and appropriately.
• Handle difficult situations in a discreet and professional manner.