Health Information Coder II
Company: Kaiser Permanente
Posted on: May 27, 2023
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, CPT, HCPCS 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, CMS, OSHPD, and Kaiser coding guidelines. As needed, Coders II may assist and be a resource for data integrity for other employees who need clarification and assistance in coding.
Positions assigned to this classification are differentiated from those assigned to the Hospital 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.
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. Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.
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, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems. Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data Including the most complicated encounters/cases.
Assigns Codes. Codes all diagnostic and operative information from the medical record using ICD-9-CM, CPT and HCPCS 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.
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 TJC, OSHPD and CMS, regional and local policy. 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. Confidentiality/Security of Systems o 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. 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. Supervisory Responsibilities: This job has no supervisory responsibilities, but may provide guidance and assistance to other coders.
Completion of classes in medical terminology, anatomy and physiology, ICD-9 and CPT coding conventions, and disease process from an accredited program.
Must have high school diploma or GED.
License, Certification, Registration
Demonstrated ability to understand the clinical content of a health record, including the most complicated records.
Must also be able to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses.
Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance.
Must be able to meet quantity and quality standards established for Coders II.
Must be able to pass Kaiser coding test at ___%.
Basic PC skills. Must maintain a minimum of ten (10) CE units annually.
Must maintain current coding credential.
Will abide by the AHIMA coding code of ethics.
Physical and Mental Demands: Ability to sit for long periods of time.
Ability to lift, push or pull 11 to 20 pounds.
Occasional bending, stooping, kneeling, crouching, reaching.
Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements.
Ability to concentrate and maintain accuracy in spite of frequent interruptions.
TITLE: Health Information Coder II
LOCATION: Oakland, California
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
Keywords: Kaiser Permanente, Oakland , Health Information Coder II, Healthcare , Oakland, California
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