HIM Coder 3

• Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes for complex inpatient and outpatient records in addition to auditing and analysis of coding related activities.
• Utilize the encoder system to sequence the codes assigned and calculate the corresponding MS-DRG/APR DRG/APC grouper.
• Abstract patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted and encounter information prior to finalizing the encounter.
• Work with a multidisciplinary team to review and discuss documentation, coding and reimbursement issues of patients and identify documentation needs for medical staff and other health care providers, providing education as needed.
• Be knowledgeable in the requirements of the industry with regard to Medicare and/or Managed care regulations, the International Classification of Diseases (ICD-9 and ICD-10-CM/PCS) and the Current Procedural Terminology (CPT) coding systems.
• Maintain quality and productivity standards established for the department and demonstrate proficiency in coding all types of high-complexity records.

The Coder 3 will, as requested, assist with mentoring or training newly on-boarded Coders, Apprentices, and clinical practice students orienting to the department. The nature of this work may require that the Coder III work on-site periodically. The Coder 3 is responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital.

Essential Functions:

• Reviewing medical records and assigning diagnostic and procedural codes using ICD-9-CM/ICD-10 CM/PCS and CPT/HCPCS and any other designated coding classification system in accordance with coding guidelines.
• Assigning and sequencing codes accurately based on medical record documentation
• Assigning the appropriate discharge disposition.
• Abstracting and entering coded data for hospital statistical and reporting requirements
• Communicating documentation improvement opportunities and coding issues to appropriate personnel for follow up and resolution.
• Adhering to accuracy and productivity levels established by the department.
• Communicating with co-workers, management, and hospital staff regarding clinical and reimbursement issues.
• Adhering to the American Health Information Management Association’s code of ethics and departmental Code of Integrity.
• Maintain coding credential along with any required CEUs for ongoing credential maintenance and subject matter expertise.