Individual is responsible for coding all OP work types (ED, CLI, REF, RCR, OBS, SDC) for the purpose of reimbursement, research, and compliance with federal regulations.   Applies ICD-10 diagnosis and CPT procedure codes and appropriate APC or E- APG.  Coder must abstract statistical data from records into hospital abstracting system in accordance with hospital policies and procedures.  Individual must have knowledge of ICD-10, CPT, APCs, E-APG’s, federal and state coding guidelines.

1. Reviews patient’s entire current medical record and assigns appropriate ICD-10 diagnosis and CPT procedure codes according to accepted coding guidelines and hospital’s policies and procedures.
2. Assigns accurate APC and E-APG’s to patient’s record utilizing hospital encoding system.
3. Corrects any edits flagged by encoder and financial system.
4. Understands and applies modifiers appropriately.
5. Accurately abstracts statistical data from records using hospital abstracting system.
6. Attends hospital sponsored coding educational programs and department coding meetings.

7. Participates in and practices lean management principles and processes.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

1. Associates or bachelor’s degree in Health Information Technology from an AHIMA/CAHIIM                     accredited college or graduate of an AHIMA accredited medical coding program.
2. 3 year of hospital coding experience.
3. Must pass the DCH coding proficiency assessment for outpatient coders.
4. Some computer or computerized encoder experience required.
5. RHIA, RHIT, CCS or CIRCC preferred.

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WORKING CONDITIONS

WORK CONTEXT

1. Requires the ability to work 8 hours quietly at a computer screen and keyboard/mouse.
2. Must be able to meet deadlines as assigned.
3. Requires the ability to withstand pressures of constant deadlines, audits, educational demands and changing healthcare environment.
4. Must have ability to accept criticism and to deal calmly and effectively in high stress situations.  
5. Must be able to communicate both verbally and in writing on a daily basis. 
6. Must be able to participate in groups.
7. Must be able to adapt to changes in work area as assigned. 
8. Displays a willingness to take on responsibilities and challenges. 
9. Ability to maintain confidentiality.

PHYSICAL FACTORS

1. Hearing and vision must be normal or corrected to within normal range. 
2. Able to perform the duties with or without reasonable accommodation. 
3. This job is considered light work. Must be able to exert up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
4. This job involves standing, walking, sitting, stooping, pushing, pulling, and crouching.
5. Ability to lift up to 20 pounds occasionally and 10 pounds frequently.
6. Must have good dexterity
7. Should be able to reach and extend arms in any direction.