- Reviews the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations.
- Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
- Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form usingprocedure codes as required.
- Using the Encoder software program, determines the codes for all diagnoses and procedures.
- Determines their sequencing to legally maximize reimbursement.
- Assigns the appropriate DRG.
- Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelinesQueries physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
- Understands and applies internal policy and procedure guidelines regarding how to phrase physician queries.
- Assists the Coding Quality and Professional Manager with training of new coding staff related to hospital and professional coding guidelines, encoder and other software systems needed for the coding process, along with reviewing coding guidelines on an annual basis and makes recommendations for change to improve coding and data management.
- Communicates to Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc.
- documented within patient records to ensure that appropriate diagnosis and procedure codes are selected and incorporated into hospital and professional coding guidelines.
- Updates and corrects historical file data by completing and submitting claim action reports per the PHC4 quarterly report.
- Works in conjunction with other areas within the revenue cycle and external departments and Geisinger to ensure coordinated activities with respect to all revenue cycle needs.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
*Relevant experience may be a combination of related work experience and/or completed specialty training program (1 year of specialty training = 1 year relevant experience).
This posting reflects an opening for Coder I and we are seeking candidates for that position. Geisinger reserves the right to consider applicants for higher levels of this role to include Coder II based on their skills, qualifications, and experience. We encourage all qualified individuals to apply.
LEVEL II requirement:
One relevant certification from AHIMA or AAPC is required upon hire. Acceptable certifications include:
AHIMA (American Health Information Management Association):
Certified Coding Specialist (CCS)
Certified Coding Specialist – Physician-based (CCS-P)
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Coding Associate (CCA) – Candidates with only a CCA are required to obtain a CCS, RHIT, or RHIA within 12 months of hire.
All certifications are acceptable from AAPC (American Academy of Professional Coders) except:
Scribe, Documentation, Instructor, and International Credentials
Certified Professional Biller (CPB)
Revenue Cycle Management Specialist (RCMS)
Certified Value-Based Administrator (CVBA)
Certified Physician Practice Manager (CPPM)
Certified Professional Compliance Officer (CPCO)
