DEPARTMENT: Health Information Management Coder II SCHEDULE: Full time, Regular, 40 hrs/wk, Day Shift Tuesday thru Saturday 7:00am - 3:30pm EDUCATION: High School Graduate LICENSE/CERTIFICATION: RHIA, RHIT or CCS QUALIFICATIONS: Under indirect supervision , is responsible for accurate coding of all inpatient, and outpatient services, procedures ,diagnoses and conditions, working from the appropriate documentation in the medical record.

Classification systems include ICD-9-CM and CPT as well as other specialty systems as required by diagnostic category.

All work is carried out in accordance with the rules, regulations and coding conventions of the American Hospital Association (Coding Clinic), ICD9, HCFA, OSHPD, and Kaiser Coding Guidelines.

As needed, Coders II may be required to assist and be a resource for data integrity and the work of Coders I and/or other employees in the Health Information Management Department who need instruction and assistance in coding e.

g., defining charts by diagnoses or procedures.

May also be required to provide professional guidance, advice and instruction to Coders I.

Positions assigned to this classification are differentiated from those assigned to the Health Information Coder I classification in that only the former are typically characterized by the performance of a higher, more complex and responsible level of work generally associated with - but not limited to - the coding of in-patient Medicare medical records/data.

Coders II also differ from Coders I in the type and amount of supervision received; responsibility for data comprehensiveness and quality assurance; direction provided to other staff; data analysis, knowledge of procedures related to the sequencing of diagnoses and interventions, as well as data management policies and procedures; required quantity and quality performance standards.

Must be willing to work in a labor-management partnership environment.

SKILLS TESTING: N/A DUTIES: 35% Review medical records to identify diagnoses/procedures.

Independently organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.

Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM, Uniform Hospital Discharge Data Set, and Medicare Guidelines.

Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data Including the most complicated encounters/cases 55% Assigns Codes Codes alldiagnostic and operative information from the medical record using ICD-9-CM and CPT coding classification systems and independently quality checks own work.

Selects the DRG for each inpatient case.

Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions.

Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.

Verifies and abstracts, all medical data from the record to complete a data abstract on each hospital encounter.

Corrects data as appropriate.

Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, OSHPD and HCFA, regional and local policy.

5% Completion of Medical Records: Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.

Enters patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract data prior to transmitting case to Government Reimbursement for billing.

Ensures timely record availability by meeting established coding and abstracting productivity standards.

Independently conducts medical record documentation auditing to monitor physician compliance with regulatory requirements i.

e., Physician Review Project.

5% Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.

Demonstrates knowledge of security of systems by not sharing computer logons.

Other Duties: Answers the telephone promptly and identifies themselves and the department.

Trains and instructs employees as appropriate .

Acts as an expert resource person to other coders and personnel in other hospital departments regarding coding questions and issues.

Other duties as assigned by supervisors.

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