Hospital Outpatient Coder
Posted on: January 18, 2023
Under direct supervision, the Hospital Outpatient Coder is
responsible for the accurate coding and abstracting of diagnoses,
conditions and procedures from medical record documentation for
Hospital Ambulatory Surgery (HAS), Home Health/Hospice (if
applicable), Observation (OBS) and -Hospital complex Outpatient
Visit (CHOY) including capture of codes for outpatient services
that require monitored anesthesia and conscious sedation. -Working
from appropriate documentation, assign the appropriate codes and
modifiers with ICD-CM, CPT and HCPCS Level II codes. -All work must
be performed in accordance with the rules, regulations and coding
conventions of ICD-CM Official Guidelines for Coding and Reporting,
Coding Clinic published by the American Hospital Association, the
ICD-CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD
and Kaiser Permanente's organizational and institutional coding
guidelines. -Essential Responsibilities:
- Review Medical Records to identify diagnoses/procedures.
- Reviews medical record documentation to identify
diagnoses/procedures to be coded Independently organizes and
prioritizes work assignments to ensure that records are coded
timely and compliantly in conformance with regulatory
- Codes all appropriate diagnosis and procedures from the medical
record using ICD-CM,
- CPT and HCSPCS coding classification systems.
- Responsible for the sequencing of diagnoses and procedure codes
in accordance with guidelines outlined in ICD-CM, CPT, Uniform
Hospital Discharge Data Set, Medicare regulations and other
appropriate classification systems.
- Verifies and abstracts the appropriate data from the medical
records to meet requirements for data submission and reporting.
Corrects data as needed.
- Ensures that all data abstracted is consistent with guidelines
outlined by TJC, OSHPD, CMS, and regional and local KP
- Ensures the accuracy and integrity of data abstracted and coded
based on medical record documentation prior to data submission or
- Interacts with physicians to clarify and accurately document
patient diagnostic and procedural information when
- Ensures timely data completion by meeting coding/abstracting
productivity/quality standards established for the position.
- Confidentiality/Security of Systems: Maintains and complies
with policies and procedures for confidentiality of all patient
- Demonstrates knowledge of privacy and security of systems and
associated policies and procedures for maintaining the security of
the data contained within the systems.Other Duties: Performs other
duties as assigned. -Grade 565Basic Qualifications:Experience
- Two years of continuous hospital coding/abstracting experience
within the last five years.Education
- High School Diploma or GED and demonstrated completion of
classes in medical terminology, anatomy, physiology, current ICD-CM
and CPT coding conventions and disease process from an accredited
program. License, Certification, Registration
- Any one of the following: CCS or CCS-P or CPC or CCA or RHIT or
- Achieve a minimum score of 75% on the Hospital Outpatient Coder
- Basic knowledge of and use of computer keyboard and mouse.
- Must be able to meet productivity and quality standards
established for the position.
- Demonstrated ability to understand the clinical content of a
health record and translate into the appropriate code.
- Demonstrated knowledge of anatomy, physiology, medical
terminology and disease process to interpret general medical
classifications for Hospital Ambulatory Services, Home
Health/Hospice, and Hospital Observation.
- Services and CHOY services that require monitored anesthesia or
- Demonstrated knowledge pertaining to all guidelines that
concern the coding and sequencing of diagnoses and procedures
outlined in but not limited to current ICD-CM, CPT, Medicare
guidelines and other sources.
- Basic knowledge of reimbursement methodologies and conventions
and knowledge of rules and guidelines for the appropriate and
current coding classifications.
- Must maintain coding credential and complete the required
Continuing Education (CE) units.
- Must abide by the AHIMA and/or AAPC code of ethics.
- Must be willing to work in a Labor Management Partnership
- N/AJob Schedule: Job Category: Health Information
Keywords: Kaiser, Petaluma , Hospital Outpatient Coder, Other , Petaluma, California
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