Outpatient Coder 2

HIM Outpatient Coder 2 is responsible for coding and abstracting outpatient medical records, including outpatient surgeries, GI procedures, and cardiac catheterizations. This role reviews clinical documentation in the patient health record to accurately assign and sequence ICD-9 and CPT codes for reimbursement and data collection, with the ability to transition to ICD-10-CM/PCS.

Responsibilities include:

• Code outpatient surgeries, including GI procedures and cardiac catheterization procedures using ICD-9 or CPT codes as appropriate.
• Maintain a yearly average accuracy rate of 94% during internal and/or external coding audits.
• Verify patient information, identify discrepancies, and ensure all codes and abstracted information are applied to the correct encounter.
• Review records for coding purposes and identify any documents not belonging to the patient or encounter.
• Use appropriate modifiers when coding outpatient encounters.
• Query physicians when needed to clarify diagnoses, symptoms, or reasons for services provided.
• Ensure codes reflect care rendered to support patient safety, accurate data retrieval, and correct reimbursement.
• Evaluate documentation for internal consistency and compliance with accreditation standards.
• Report unusual circumstances and/or possible risk factors to leadership.
• Maintain continuing education requirements established by AHIMA and/or AAPC.
• Meet productivity standards according to AHIMA guidelines based on outpatient record type.
• Participate in ICD-10-CM/PCS education sessions and demonstrate competency.
• Follow HIPAA guidelines, administrative policies, and applicable laws and regulations.
• Demonstrate service excellence and CARE values: Compassion, Accountability, Respect, and Expertise.
• Perform other related duties as assigned.