Under direct supervision, the Hospital Outpatient Coder is responsible for accurate coding and abstracting of diagnoses, conditions, and procedures from medical record documentation for Hospital Ambulatory Surgery (HAS), Home Health/Hospice (if applicable), Observation (OBS), and Hospital complex Outpatient Visit (CHOY), including services that require monitored anesthesia and conscious sedation.
Working from appropriate documentation, the role assigns codes and modifiers using ICD-CM, CPT, and HCPCS Level II. All work must follow ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic guidance, AHA coding conventions, ICD-CM/CPT/HCPCS code books, CPT Assistant, NCCI edits, OSHPD, and Kaiser Permanente organizational and institutional coding guidelines.
Essential responsibilities
- Review medical records to identify diagnoses and procedures to be coded
- Independently organize and prioritize work to ensure timely and compliant coding
- Code diagnosis and procedure data using ICD-CM, CPT, and HCPCS classification systems
- Sequence diagnoses and procedures according to applicable guidelines and regulations
- Abstract and verify data for reporting and submission, correcting data as needed
- Ensure data consistency with TJC, OSHPD, CMS, and regional/local Kaiser Permanente policies
- Maintain accuracy and integrity of coded and abstracted data before submission
- Communicate with physicians to clarify documentation when appropriate
- Meet productivity and quality standards for coding and abstracting
- Maintain confidentiality and comply with system security policies
- Perform other duties as assigned
Basic qualifications
- Two years of continuous hospital coding/abstracting experience within the last five years
- High school diploma or GED
- Completion of coursework in medical terminology, anatomy, physiology, current ICD-CM and CPT coding conventions, and disease processes from an accredited program
- One of the following credentials: RHIT, CPC, CCS, CCA, RHIA, or CCS-P
Additional requirements
- Minimum score of 75% on the Hospital Outpatient Coder test
- Basic knowledge of computer keyboard and mouse use
- Ability to meet productivity and quality standards
- Demonstrated ability to interpret medical record documentation and assign appropriate codes
- Knowledge of anatomy, physiology, medical terminology, and disease processes
- Understanding of coding and sequencing guidelines for ICD-CM, CPT, Medicare, and related sources
- Basic knowledge of reimbursement methodologies and coding conventions
- Must maintain coding credentials and required continuing education units
- Must comply with AHIMA and/or AAPC code of ethics
- Must be willing to work in a Labor Management Partnership environment
Location
California, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
3 weeks ago