The Coder III is responsible for accurate inpatient and outpatient coding, analysis, and screening records for billing, research, and special studies. Responsible for the timely and accurate coding of administrative and clinical data through the accurate assignment of ICD-10 and/or CPT codes and APC and DRG Assignment and modifiers.

Duties/Responsibilities:

• Ensures the correct ICD-10-CM, ICD-10-PCS, APC, and DRG Assignment and/or CPT code and modifiers to each diagnosis and procedure are substantiated by documentation contained in the medical record.
• Follows departmental and official ICD-10-CM, ICD-10, -PCS APC Assignment and/or CPT coding guidelines to ensure consistent and accurate diagnostic and procedural data coding.
• Assists with and requests diagnoses from medical staff when not recorded in medical records or if information is incomplete.
• Corrects edits with the patient accounts staff to ensure timely billing of accounts and resolution of potential errors.
• Ensures records are coded timely and within department-defined timelines.
• Thoroughly reviews charts to identify all diagnoses/procedures.
• Refers questions to the supervisor if there are questions regarding the diagnoses/procedure code.
• Utilizes computerized encoder for assignment of ICD and CPT codes. Refers to the coding book for additional information and/or code verification.
• Codes all diagnoses/procedures per the Health Information Management Coding Manual and AHIMA’s Standards of Ethical Coding.
• Inputs/abstracts, diagnoses/procedure codes into the abstracting and billing systems.
• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.

Education:
High School Diploma or equivalent required. Completion of certified ICD 10/CPT coding courses/education or equivalent work experience preferred.

Experience:
Health Information Management experience required. At least one year of experience in abstracting and coding in ICD required. DRG and CPT, including modifiers and APC assignment, required.

Licensure/Certification:
Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Registered Health Information Technician (RHIT) required. Based on the department's needs, select other AAPC or AHIMA certifications may be considered.

Physical/Work Requirements:
The physical demands described here represent those that an employee must meet to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is required to communicate effectively. Specific vision abilities this job requires include close vision for reading and computer work. The employee must lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move more than 50 pounds.

The work environment described here is representative of those that an employee must meet to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee works in an area with good lighting and climate control. The noise level in the work environment is usually moderate.