Outpatient Medical Coder Lead

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Job Title:

Department:

Scope of Position
Coding services assigns diagnosis and procedural codes to outpatient medical records to facilitate the reimbursement and data collection for the individual business units of the OSU Health System. ICD-10-CM diagnosis and CPT-4 procedure codes are applied to all outpatients treated within the OSU Health System that are not captured through the charge description master. Medical record abstract data is assigned based on information reviewed for accuracy in IHIS during the coding process. This position is responsible for training medical record coding specialists and coding some or all the following types of records: emergency department, ambulatory surgery, Talbot, outpatient clinic, pain block and ancillary areas. The Lead Coding Specialist will also participate in hospital’s trauma registry.

Position Summary
The position is responsible for training and supporting new medical record coding specialists. The Lead Coder’s responsibilities also include auditing the coding of records, assuring outpatient coding policies and procedures reflect practice, ensuring the integrity of information in the electronic medical record, and monitoring completion of coding activities. This position also codes medical records and other documents at the conclusion of the patient’s visit. This requires selection of appropriate admitting diagnosis, principal and secondary diagnoses, principal procedure and secondary procedures; assigning accurate ICD-10 and/or CPT-4 codes; sequencing the diagnoses and procedures codes; and abstracting information including admission source, type, disposition, admitting, attending and procedure attending physicians. Codes are selected in the Encoder Software following review of information in the electronic medical record system, IHIS. Information abstracted and coded is interfaced to IHIS Resolute Billing system. This staff member is responsible to address all edits during the coding and abstracting process for complete and accurate coding assignment for hospital reimbursement. This staff member will maintain productivity and quality standards set for the department maintain an approved work schedule and submit a weekly volume log.

The Outpatient Lead Coder may also provide area coverage in the absence of a manager.

Minimum Qualifications
For hire or promotion:
Associate Degree in Health Information Management or other qualifying associate degree in health care
OR
Minimum two years of daily hospital coding production specific to the area of discipline (i.e. outpatient coding). Generally, lead medical records coding specialists are outpatient coders promoted from the medical records coding specialist role or senior medical records coding specialist role at OSUWMC.
AND
Accredited as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) by the American Health Information Management Association, or Certified Outpatient Coder (COC) by AAPC or CPC with CHONC
AND
Minimum of two years academic medical coding experience.
Outpatient: emergency, observation, outpatient, ASU and James series.
On Going:
Maintain continuing education requirements as determined by the American Health Information Management Association or American Academy of Professional Coders. Review Coding Clinics, CPT assistant as frequently as needed for education purposes, and to ensure the official coding guidelines are followed.
The lead medical records coding specialist attends coding meetings and coding education sessions for updates on coding guidelines and related issues while maintaining a minimum score of 90% on coding assessments quarterly.

Additional Information:

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