Fully Remote,  Must live in Florida

Orientation onsite in St Augustine first 2 days

The Coder II position assigns diagnoses and procedure codes to Observation and Same Day Surgery medical records.

• Assigns correct ICD-10-CM code to all diagnoses and correct CPT code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical in order to retrieve proper documents (i.e. discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity
• Reads and understands operative reports in order to classify to most accurate CPT codes. Researches complex operations as necessary.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Assigns correct modifier on CPT codes that are required under the Medicare APC reimbursement.
• Maintains a thorough knowledge of the use of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies. Maintains a positive working relationship with physicians in order to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains a thorough knowledge of the prospective payment system and any new codes or DRG’s added/changed each year. Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as the ICD-9-CM coding conventions, Coding Clinic, and other official recourses to substantiate the most appropriate, correct code assignment. Stays abreast of Medicare’s medical review policies and incorporates updates and changes into the coding process.

Education / Training

• High School Diploma/Equivalent

Preferences:
Graduate of a Health Information Management Program

Experience Requirements

• 1-year Medical Record Coding

Certificates/Licenses/Registration

• Any AAPC or AHIMA Medical Coding Certification