HEALTH INFORMATION MANAGEMENT CODER I/II

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1 Monterey County I 50T02 II 50T03 HEALTH INFORMATION MANAGEMENT CODER I/II DEFINITION Under general supervision, reviews, interprets, codes and abstracts medical records information according to standard classification systems; identifies diagnostic categories based on medical, diagnostic and related hospital services rendered and other related patient information; reviews medical records for adherence to quality standards; and performs other related duties as assigned. DISTINGUISHING CHARACTERISTICS This is the entry-level class of the Health Management Coder classification series. Incumbents initially work under close supervision and learn to perform the more routine coding functions pertaining to outpatient medical records. As experience is gained, employees learn to code the more difficult inpatient medical record information. This class is flexibly staffed with Health Information Management Coder II, and incumbents normally advance to the higher level after gaining experience and achieving proficiency that meets the requirements for the higher level. Health Information Management Coder II: This is the full, journey level class in this series. Incumbents perform the full scope of duties involving the coding of both outpatient and inpatient medical records, and may perform other special assignments as related to the Health Information Management division. The Health Information Management Coder II class may be distinguished from the higher-level class of Health Information Management Coding Supervisor (HIM Coding Supervisor) in that incumbents in the latter class function as first level supervisors in the unit, with full scope responsibilities for assigning, directing, monitoring and evaluating the work of subordinate staff on a regular basis, in addition to performing the most technically difficult coding duties in the division. EXAMPLES OF DUTIES Nothing in this specification restricts management s right to assign or reassign duties and responsibilities to this job at any time. Depending upon classification level, incumbents may perform any of the following: 1. Depending upon assignment, reviews and codes inpatient and/or outpatient medical record information; assigns codes using the International Classification of Diseases Manual (ICD-9- CM), the American Medical Association s Current Procedural Terminology (CPT) manual, and/or the Healthcare Common Procedure Coding System (HCPCS) codes and modifier assignments; establishes Ambulatory Payment Classification (APC) and/or Diagnosis Related Group (DRG) group appropriateness; identifies and codes secondary diagnoses and/or procedures; ensures compliance with all APC and/or DRG mandates and reporting requirements. 2. Abstracts Office of Statewide Health Planning and Development (OSHPD) data elements and assists the HIM Coding Supervisor with correcting and submitting data. 3. Monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas. 4. Evaluates the quality of clinical documentation on a continuous basis to identify incomplete or inconsistent documents for inpatient and/or outpatient encounters that impact the code selection and resulting APC/DRG groups and payment; brings concerns to the attention of the HIM Coding Supervisor and/or medical staff for resolution 5. Maintains knowledge of current and required coding certifications as appropriate.

2 6. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association; reports areas of concern to the HIM Coding Supervisor. 7. Assists the HIM Coding Supervisor by serving as a facility representative for DRG s and/or APC s by attending coding and reimbursement workshops and bringing back information as appropriate; communicates any DRG/APC updates published in third-party payer newsletters, bulletins and/or provider manuals; shares information with facility staff as directed. 8. Assists the HIM Coding Supervisor in performing data quality reviews on inpatient records to validate the International Classification of Diseases Manual (ICD-9-CM), and other codes; verifies Diagnosis Related Group (DRG) group appropriateness; checks for missed secondary diagnoses and procedures and ensures compliance with all DRG mandates and reporting requirements; monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas. 9. Assists the HIM Coding Supervisor in performing data quality reviews on outpatient encounters to validate the ICD-9-CM, the Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS) Level II code and modifier assignments; verifies Ambulatory Payment Classification (APC) group appropriateness; checks for missed secondary diagnoses and/or procedures; ensures compliance with all APC mandates and outpatient reporting requirements; monitors medical visit code selection against facility specific criteria for appropriateness; assists in the development of such criteria as needed. 10. Monitors unbilled account reports for outstanding services or un-coded discharges to reduce accounts receivable days for inpatients and/or outpatients. 11. Stays informed about transaction code sets, Health Insurance Portability and Accountability Act (HIPPA) requirements and other future issues impacting the coding function; keeps abreast of new technology in coding and abstracting software and other forms of automation. 12. Demonstrates competency in the use of computer applications, particularly the coding and abstracting software and hardware currently in use by the Health Information Management division. 13. Assists the HIM Coding Supervisor in performing periodic claim form reviews to check code transfer accuracy from the abstracting software and the charge master; may serve on a charge master maintenance committee. 14. Compiles statistics and prepares/maintains a variety of records and reports; finalizes attending physician attestations and obtains signatures; researches and locates missing data and records needed for coding and abstracting; retrieves files and records. 15. Performs other related duties as assigned. QUALIFICATIONS Licenses/Certificates: Possession of a national certification or registration in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS), a Registered Health Information Technician (RHIT) or a Registered Health Information Administrator (RHIA) is highly desirable. 2

3 A combination of experience, education, and/or training which substantially demonstrates the following knowledge, skills and abilities: Knowledge and Skills: Knowledge of: 1. Medical record keeping principles and practices; the nature and uses of medical records charges; basic medical terminology, anatomy, and physiology. 2. Basic functions of a hospital medical records division; legal aspects of medical record administration. 3. ICD-9-CM, CPT, and HCPCS Level II coding systems. 4. The APC structure and regulatory requirements. 5. Basic keyboard operations and the operation of standard office equipment; standard business computer hardware and software. 6. The business and professional relationships and ethics involved among hospitals, physicians and patients. Health Information Management Coder II (in addition to the above knowledge requirements): Thorough Knowledge of: 1. The current Diagnostic and Statistical Manual of Mental Disorders (e.g., DSM IV-TR). 2. Current hospital reimbursement systems and associated regulatory review practices. 3. Governmental and Joint Commission (JCAHO) standards for medical records. 4. States, sequence, progression and description of diseases. Skill and Ability to: 1. Read, interpret and evaluate complex technical reports and information. 2. Understand and apply anatomical, physiological and medical terminology. 3. Operate a personal computer. 4. Maintain records and compile statistics. 5. Communicate clearly and concisely, both orally and in writing; prepare reports and other written communications. 6. Provide excellent public relations and courteous customer service; establish and maintain cooperative working relationships with others including physicians, nurses, administrators, managers, vendors, contractors and other health care industry personnel. Health Information Management Coder II (in addition to the skills and abilities listed above): 3

4 1. Interpret both outpatient and inpatient medical records to assign diagnostic codes and prepare medical record abstracts. 2. Understand disease processes, advanced medical terminology, diagnostic descriptions and procedures. 3. Evaluate the quality, completeness and accuracy of medical records. 4. Work with physicians and others to ensure complete and accurate information and optimal reimbursement based on coding and abstracting of medical records. REQUIRED CONDITIONS OF EMPLOYMENT As a condition of employment, the incumbent will be required to: 1. Be willing to tolerate frequent exposure to dust; willingness to work shifts and be subject to calls outside of working hours. 2. Pass a pre-employment physical/medical assessment and background check. 3. Be willing to work in an environment with potential exposure to potentially hazardous and infectious substances/organisms such as bodily fluids or blood. EXAMPLES OF EXPERIENCE/EDUCATION/TRAINING Any combination of training, education and/or experience which provides the knowledge, skills and abilities and required conditions of employment listed above is qualifying. An example of a way these requirements might be acquired is: Experience: Option I One year of experience which has involved either work with Medical Records coding and/or billing, or the analysis/evaluation of technical reports/information to determine appropriate coding; Vocational or college level coursework in Anatomy, Physiology, and Medical Terminology. and or Option II Completion of a community college, vocational school, or equivalent program in Medical Records Coding and Abstracting. Health Information Management Coder II: Experience: Two years of experience equivalent to the class of Health Information Management Coder I in Monterey County. 4

5 Completion of a community college, vocational school, or equivalent program in Medical Records Coding and Abstracting. PHYSICAL AND SENSORY REQUIREMENTS and The physical and sensory requirements for this classification include: 1. Mobility and Lifting: Frequent sitting for extended periods of time; frequent standing; frequent lifting up to 25 pounds. 2. Visual: Constant ability to read information, including close up; constant ability to use a computer screen; frequent use of good overall vision, including color perception. 3. Dexterity: Constant eye and hand coordination and manual dexterity to write, operate a computer keyboard and finely manipulate small objects. 4. Hearing/Talking: Constant ability to hear normal speech; frequent ability to hear and talk on the telephone and in person. 5. Emotional/Psychological: Constant ability to make decisions and concentrate. 6. Special Requirements: Frequent exposure to dust. CLASS HISTORY CLASS DATA Class Code I: 50T02 Job Group I/II: 14 II: 50T03 Established Date: March 2007 EEO Category: T Revised Date: Work Comp. Code: 8830 Former Title: Bargaining/Employee Unit: J FLSA: C MOCO OT: Y Prepared by: JC /s/ Janine Bouyea, NMC Human Resources Administrator County Administrative Office 9/10/2008 Date 5

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