Assigning appropriate diagnostic and procedure codes to the patient's health information records for records from the Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), Inpatient (IP), and other chosen facility records. Maintain an acceptable level of performance for the ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification and nomenclature systems in terms of quality and productivity. The American Medical Association (CPT), National Correct Coding Initiative (NCCI), Uniform Hospital Discharge Data Set (UHDDS), Medicaid, and the International Classification of Diseases – Official Coding Guidelines for coding and reporting as established by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) will all be followed (OMAP), and institutional/organizational coding policies of Kaiser Permanente. having the ability to ask doctors for clarification on diagnoses and procedures. Ability to comprehend the clinical information contained in the health record, extract the data from the patient's health information record, and carry out additional tasks that have been delegated. The new programmer must train on-site for one (1) week or until they meet the department's requirements, whichever comes first.

Significant Duties:

Proficient at reviewing medical records and converting clinical data into codes. Determine the proper codes to use for diagnoses, procedures, and other rendered services, and validate any Computer Assisted Coding (CAC) assignments for dual coding. Analyzing and maintaining system accuracy, validity, and meaningfulness for both professional and facility services while using the Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software system for professional surgical services. uses the clinical information system (EpicCare) and electronic patient data system to retrieve patient encounter data. clinical data elements that are determined by the needs of the organization are abstracted and entered. identifies and assigns the primary diagnosis and procedure codes, arranging them in the appropriate order for the correct Ambulatory Payment Classification (APC), Utilizing the appropriate coding methods, the Medicare Severity-Drug Related Group (MS-DRG), All Patients Refined Diagnosis Related Groups (APR-DRG) assignment. displays understanding and knowledge of CMS HCC Risk Adjustment Code.

Regularly analyzes charts to find parts of the medical file that have documentation that is lacking, wrong, or inconsistent. reviews and confirms the data on the charts (i.e. POS, attending provider). evaluates and enters data. To verify the correctness and completeness of diagnostic and therapeutic treatments that must adhere to CMS coding regulations and guidelines, reviews and verifies component sections of medical records. 95% of departmental standards are met and maintained for productivity and quality.

Employs all of the resources at their disposal, including the Coding Clinic and CPT Assistant, to fully explore coding-related issues. identifies code issues and alerts managers and supervisors as necessary. employs the query process as necessary. helps put solutions into practice that will cut down on back-end code errors. to minimize the risk of fraud and abuse and to maximize revenue recovery, one keeps up with coding and regulatory publications and attends workshops to stay informed about current issues, trends, and changes in the laws and regulations governing medical record coding and documentation.

Maybe lend a hand on particular projects. Keep your conversations private and your interactions with staff productive. exercising independent judgment and being able to speak in a clear and understandable way. Reviews the quarterly Coding Clinic and the monthly CPT Assistant, as well as the annual ICD-10 Official Guidelines for Coding. Participates actively in staff meetings, reporting of performance metrics, quality result monitors, and facility coding services team activities as a team member. May take part in creating organizational policies. attends and takes part in a number of national and regional coding education sessions. Perform other duties as assigned.