Certified Coder II

Job Summary

Reviews clinical documentation and diagnostic results to extract data and apply appropriate ICD-10-CM, PCS, CPT, and HCPCS codes for billing, internal and external reporting, research, and regulatory compliance. Codes inpatient and observation conditions and procedures in accordance with ICD Official Guidelines for Coding and Reporting, with expert knowledge of MCC/CCs. Resolves error reports associated with the billing process, identifies and reports error patterns, and assists with workflow changes to reduce billing errors.

Essential Functions

• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for all assigned encounters.
• Reviews provider documentation to determine principal diagnosis, comorbidities, complications, secondary conditions, and surgical procedures.
• Uses technical coding principles and MS-DRG reimbursement expertise to assign appropriate ICD diagnoses, procedures, present-on-admission indicators, and other applicable codes.
• Extracts required information from source documentation and enters it into the encoder and abstracting system.
• Identifies non-payment conditions (HAC) and reports them through established procedures when required.
• Works with physicians and department representatives to improve processes, documentation, and efficiency.
• Follows AHIMA Standards of Ethical Coding and adheres to official coding guidelines and internal coding policies and procedures.