The OP Coder is responsible for assigning diagnostic and procedural codes (outpatient surgery, observation, infusion services, and interventional procedure records) to patient charts, of moderate to high complexity, using: ICD-10-CM, CPT and HCPCS or any other designated coding classification system in accordance with coding rules and regulations. They abide by the Standards of Ethical Coding as set forth by AHIMA. Abstracting required clinical information from the medical record.

Responsibilities and Duties:

• The following responsibilities and duties:
o Coding: Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Adheres to Standards of Ethical Coding (AHIMA).
o Abstracting: Reviews medical records to determine accurate required abstracting elements (facility/client specific elements) including appropriate discharge disposition.
o Coding Quality: Demonstrates ability to achieve accuracy and consistency in the selection of principal and secondary diagnoses (including MCC & CC) and procedures. Demonstrates ability to achieve accuracy and consistency in abstracting elements defined by per facility.

• Proficient in outpatient diagnosis coding guidelines
• Proficient in CPT/HCPCS code assignment including Evaluation & Management facility coding guidelines
• Ability to assign corresponding PCS codes (after dates of service 10/1/2014) preferred but not required
• Working knowledge of the Outpatient Prospective Payment System (OPPS)
• Adept at comparing documentation, code assignment and charge in the financial system for accuracy and completeness and elevating concerns to the appropriate manager
• Functional knowledge of facility EMR, encoder and other support software
• Ability to establish and maintain effective working relationships as required by the duties of the position
• Ability to concentrate and accomplish tasks with explicit accuracy
• Ability to use office equipment and automated systems/applications/software at an acceptable level of proficiency