Coding Specialist II - Facility Outpatient (Ambulatory Surgery)
- Columbia, MD
- Permanent
- Full-time
Codes and abstracts primarily Ambulatory Surgery records and other outpatient records using ICD-10-CM, and other applicable patient classification schemes.Primary Duties and Responsibilities
- Abstracts and ensures accuracy of diagnoses, procedure, patient demographics, and other required data elements.
- Adhere to all compliance regulations and maintains annual compliance education.
- Maintains continuing education and seeks ongoing education to improve job performance. Maintains credentials as required for job classification.
- Contacts physician when conflicting or ambiguous information appears in the medical record. Adheres to the MedStar Coding Query Policy and procedure.
- Meets established Quality standards as defined by policies.
- Meets established Productivity standards as defined by policies.
- Resolves all quality reviews timely (e.g. Medical necessity reviews; Coding Quality assurance reviews; external vendor reviews).
- Reviews medical record documentation to identify diagnoses and procedures. Assigns correct diagnostic, procedural codes, and appropriate modifiers using standard guidelines and automated encoding software maintaining departmental accuracy standards.
- Exhibits knowledge of the 3M system and other work-related equipment.
Education
- High School Diploma or GED required
- Associate's degree or Bachelor's degree in coding related degree preferred
- Courses in Medical Terminology, Anatomy & Physiology, ICD-CM and CPT-4 required
- 2 years ASU (Ambulatory Surgery) coding experience and experience with clinical information systems (3M grouper, electronic medical records, computer assisted coding) required
- CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist-Physician-based) required or COC (Certified Outpatient Coder) required
- RHIT (Registered Health Information Technician) preferred and/or RHIA (Registered Health Information Administrator) preferred
- Verbal and written communication skills.
- Basic computer skills required.