In accordance with federal coding compliance regulations and guidelines, use current ICD-10-CM, CPT-4, and HCPCS code sets/systems to accurately abstract, code, and electronically record into the 3M Coding & Reimburse System (3M-CRS) & the coding abstracting system (3M-ClinTrac), all diagnoses and minor invasive and non-invasive procedures, documented by any physician in outpatient medical records (i.e. OP Ancillary visits: Laboratory, Radiology etc.; Clinic Visits; Radiation Oncology; Recurring Visits, etc.). Address OCE/NCCI edits within 3M-CRS and those returned from the Business Office. Understands PFS coding/billing processes & systems such as PBAR and nThrive/MedAssets/XClaim in a manner to assure claims drop timely with appropriate codes. Performs other coding department related duties as assigned by HIM management staff.

Essential Duties:

• Outpatient Ancillary/Clinic Visit/Emergency Department coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions.
• Reviews the entire medical record; accurately classify and sequence diagnoses and procedures; ensure the capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co-morbidities, historical condition or family history that has an impact on current care or influences treatment, and all external causes of morbidity.
• Enter patient information into inpatient and outpatient medical record databases (ClinTrac/HDM). Ensures accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission.
• Works cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist in obtaining documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes.
• Assists in the correction of regulatory reports, such as OSHPD data, as requested.
• Attendance, punctuality, and professionalism in all HIM Coding and work related activities.
• Consistently assumes responsibility and displays reliability for completion of tasks, duties, communications and actions. Completes tasks accurately, legibly, and in a timely fashion.
• Performs other duties as requested/assigned by Director, Manager, Supervisor, or designee.
• Ability to achieve a minimum of 95% coding accuracy rate as determined by any internal or external review of coding and/or department quality review(s).
• Ability to achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by any internal or external review of coding and/or department quality review(s).
• Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting.
• Recognizes education needs of based on monthly reviews and conducts self-improvement activities.
• Ability to act as a resource to coding and hospital staff on coding issues and questions.
• Ability to improve MS-DRG assignments specific to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APR-DRG, SOI, and ROM assignments specific to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APC/HCC assignments specific to medical necessity documentation & coding of PDx, SecDx, and CPT/HCPCS in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Maintains at minimum, expected productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of productivity and provides consistent effort.
• Works coding queues/task lists to ensure 95% of patient bills are dropped within 5 days after patient discharge/date of service.
• Works coding queues/task lists to ensures the remaining 5% of patient bills are dropped within 2 weeks of discharge/date of service.
• Assist other coders in performance of duties including answering questions and providing guidance, as necessary.
• Assists Patient Financial Services (PFS), Patient Access, and other departments in addressing coding issues/questions and/or providing information so that an interim bill can be generated. Assists with physicians, physician office staff and hospital ancillary department staff with diagnostic or procedural coding issues/questions, as needed.
• Assists in the monitoring unbilled accounts to ensure that the oldest records are coded and/or given priority.
• Maintains AHIMA and or AAPC coding credential(s) specified in the job description.
• Attend coding & CDI seminars, webinars, and in-services to maintain the required annual continued education units (CEU).
• Keep up-to-date and reviews ICD-10 Official Guidelines for Coding & Reporting, AHA Coding Clinic, and CPT Assistant to maintain knowledge of the principles of coding.
• Keep up-to-date and reviews other professional journals and newsletters in a timely fashion to maintain knowledge of the principles of coding.
• Consistently attend and actively participate in the daily huddles.
• Consistently adhere to HIM policies and procedures as directed by HIM management.
• Demonstrates an understanding of policies and procedures and priorities, seeking clarification as needed.
• Participates in continuously assessing and improving departmental performance.
• Ability to communicate changes to improve processes to the director, as needed.
• Assists in department and section quality improvement activities and processes (i.e. Performance Improvement).
• Works and communicates in a positive manner with management and supervisory staff, medical staff, co-workers and other healthcare personnel.
• Ability to communicate effectively intra-departmentally and inter-departmentally.
• Ability to communicate effectively with external customers.
• Provides timely follow-up with both written and verbal requests for information, including voice mail and email.
• Working knowledge and efficient navigation of the Electronic Health Record (EHR): Cerner/Powerchart & Coding mPage.
• Working knowledge, efficient navigation, & full use of 3M-CRS Encoder system; utilize to expedite coding process; utilize all references.
• Knowledge & understanding of PFS system (PBAR) functionality and any interface with the coding abstracting system: ClinTrac.
• Working knowledge, efficient navigation, & full use of ‘HDM/HRM/ARMS Core’ coding & abstracting software.
• Working knowledge, efficient navigation, & full use of ‘3M 360 Encompass/CAC’
• Performs other duties as assigned.

Required Qualifications:

• Req High school or equivalent
• Req Specialized/technical training Successful completion of college courses in Medical Terminology, Anatomy & Physiology and a certified coding course. Successful completion of the hospital specific coding test – with a passing score of ≥70. The coding test may be waived for former USC or agency/contract HIM Coding Dept. coders who historically/previously met the ≥ 90% internal/external audit standards of the previously held USC Job Code.

• Req Experience in using a computerized coding & abstracting database software and an encoding/codefinder systems are required.

Preferred Qualifications:

• Pref Prior experience in ICD-9 & ICD-10 (combined) and CPT/HCPCS coding of Outpatient Ancillary/ED medical records in hospital and/or outpatient clinic preferred.

Required Licenses/Certifications:

• Req Certified Coding Specialist - CCS (AHIMA) OR AHIMA Certified Coding Specialist - Physician (CCS-P); OR AAPC Certified Professional Coder (CPC); OR AAPC Certified Outpatient Coding (COC) If there is the absence of a national coding certificate and the coder possesses any one of the following national certifications, the coder will be required to pass any of the national coding examinations Re: the aforementioned coding certificates within six (6) months of employment: 1. AHIMA Registered Health Information Technician (RHIT) 2. AHIMA Registered Health Information Administrator (RHIA)
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)