Hospital Outpatient Coder

Under direct supervision, the Hospital Outpatient Coder is responsible for the 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 capture of codes for outpatient services that require monitored anesthesia and conscious sedation.  Working from appropriate documentation, assign the appropriate codes and modifiers with ICD-CM, CPT and HCPCS Level II codes.  
All work must be performed in accordance with the rules, regulations and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD and Kaiser Permanentes organizational and institutional coding guidelines.

• Review Medical Records to identify diagnoses/procedures.
• Reviews medical record documentation to identify diagnoses/procedures to be coded Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
• Codes all appropriate diagnosis and procedures from the medical record using ICD-CM,
• CPT and HCSPCS coding classification systems.
• Responsible for the sequencing of diagnoses and procedure codes in accordance with guidelines outlined in ICD-CM, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems.
• Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting. Corrects data as needed.
• Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS, and regional and local KP policies.
• Ensures the accuracy and integrity of data abstracted and coded based on medical record documentation prior to data submission or coding completion.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information when appropriate.
• Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the position.
• Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.
• Demonstrates knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
• Other Duties: Performs other duties as assigned.

Grade 565