Job Description

University of Utah Job Description

Job Summary

Abstracts demographic physician and patient information from patients’ medical records and codes the diagnoses and procedures using ICD-10-CM/CPT codes.

Qualifications

Two years of coding experience using ICD-10-CM, CPT, HCPCS or equivalency; demonstrated knowledge of medical terminology, anatomy, and physiology; and a basic knowledge of medical procedures and disease states/processes required. Computer literacy, demonstrated human relations and effective communication skills also required.

There are two levels in the Health Information Coder position. The senior coder position is one salary grade above the junior position and requires department specific nationally recognized coding certification in addition to the minimum qualifications listed above. Departments may require the senior coder to perform higher level duties on occasion.

Departments may prefer specific certifications over others and may require junior coders to obtain certification within a specified timeframe. The incumbent is expected to complete continuing education courses to maintain required certification.

This position is patient-sensitive and must fulfill all associated vaccination requirements, or be approved for an exemption, prior to the first day of work. We protect our patients, coworkers and community by requiring all patient-sensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.

Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.

Disclaimer

This job description has been designed to indicate the general nature and level of work performed by employees within this classification.  It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to the job.

Essential Functions

1. Abstracts information from in-patient interim, discharge and out-patient medical records and inputs into a database.
2. Analyzes patient chart information for accuracy and completeness; clarifies vague or incomplete diagnostic and/or procedural information with physicians and other health care providers when necessary.
3. Assigns ICD-10-CM, CPT, ASC, APC, HCPCS, APRDRG and/or DRG codes to patient diagnoses and procedures.
4. Researches and resolves inquiries from insurance companies, physicians and patients regarding charge and coding verification.
5. Designs and runs reports for administrators, health care providers and outside agencies using the department’s computer system.
6. Completes computer-generated interfaces to assure that all coding is accurately reported to the billing department.
7. May track missing charges and work with billing companies to resolve coding and billing issues.
8. May assign the DRG sub-classification formula to Medicare/Medicaid and rehabilitation patient records.
9. May implement recommendations for internal and external DRG/Coding Auditor.
10. May round concurrently on the inpatient units and code initially for a working DRG and subsequently for a final discharge DRG.
11. May provide education to staff or providers regarding appropriate documentation and coding guidelines.

Problem Solving

Challenges encountered by the incumbent include accurately coding information when available documentation is vague or ambiguous; identifying computer problems and working with computer technicians to make necessary repairs; and coordinating with the billing office to identify unbilled accounts and locating or generating the coding required to receive reimbursement. The incumbent resolves questions or requests from various entities that involve researching and verifying coding in patient records.

This position has the authority to make decisions to optimize reimbursement within State and Federal laws. If assigned lead worker status, the incumbent is authorized to schedule, direct, and oversee the work of Health Information Coders and other subordinate department personnel. The incumbent must abide by Hospital, State, and Federal coding guidelines established by DNV, American Hospital Coding Association, and Medicare/Medicaid, etc.

Comments

Work Environment and Level of Frequency typically required

Nearly Continuously: Office environment.

Physical Requirements and Level of Frequency that may be required

Nearly Continuously: Sitting, hearing, listening, talking.

Often: Repetitive hand motion (such as typing), walking. 

Seldom: Bending, reaching overhead.

This position is patient-sensitive and must fulfill all associated requirements. We protect our patients, coworkers and community by requiring all patient-sensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.