Him Coder- Union
Company: Northwell Health
Posted on: June 10, 2021
The HIM Coder - Union performs coding and abstracting duties to
assure accurate completion of coding for all assigned patient
Analyzes and interprets the medical record in its entirety to
ensure accurate, complete and consistent selection of diagnoses and
procedures to assure the production of quality healthcare data and
accurate facility payment.
Applies understanding of basic anatomy and physiology to
interpret clinical documentation and identify applicable codes.
Utilizes resources and reference materials (e.g., on-line
sources, manuals) to identify appropriate codes and reference code
applicability, rules and guidelines.
Applies the Uniform Hospital Discharge Data Set (UHDDS)
definitions as well as any additional regulatory guidelines and/ or
coding references to select the principal diagnosis, secondary
diagnoses, all significant procedures, indicating the patient's
acuity, severity of illness and risk of mortality (if applicable),
as documented in the medical record.
Codes and reports diagnoses and their associated present on
Admission (POA) Indicator and procedures in accordance with the
established International Classification of Diseases 10th Revision
Procedure Classification System (ICD-10-PCS) Official Guidelines
for Coding and Reporting.
Accurately assigns discharge disposition for all records as
required and in accordance with the Centers for Medicare and
Medicaid Services (CMS) rules and regulations.
Make determinations on medical coding and takes initiative to
complete reviews and coding independently, to avoid delays in the
Manages multiple work demands simultaneously to maintain
relevant efficiency and turnaround time standards for completing
Assigns and reports all other data elements required for
Statewide Planning and Research Cooperative System (SPARCS) data
collection, Congenital Malformations and Expirations.
For outpatient encounters, applies coding conventions and
official coding guidelines approved by the Current Procedural
Terminology (CPT) rules established by the American Medical
Association (AMA), and any other official rules and guidelines
established for use with the mandated outpatient procedure code
Assigns appropriate discharge physician in the system.
Generates compliant physician queries to clarify any
incomplete/ambiguous or conflicting documentation and applies
post-query responses to make final coding determinations.
Demonstrates basic knowledge of the impact of coding decisions
on revenue cycle.
Assists in the education of physicians and other clinicians by
advocating proper documentation practices, further specificity,
resequencing and inclusion of diagnoses or procedures when needed
to more accurately reflect the acuity, severity of illness and risk
of mortality as indicated..
Attends and participates in required hospital education programs
in order to maintain and enhance their coding skills and stay
abreast of changes in codes, coding guidelines and regulations.
Maintains the minimum data standards for accuracy and efficiency
as defined by the facility.
Maintains certified coding credentials in accordance with the
certified coding requirements and demonstrates annual
- Performs related duties, as required.
Certified Coding Specialist (CCS) or Certified Professional
Coder (CPC) or Certified Coding Specialist-Physician (CCSP),
Certified Inpatient Coder (CIC), or Certified Outpatient Coder
(COC), required. Successful completion of a medical coding course,
Minimum of two (2) year experience as an ICD-10
Outpatient/Inpatient medical records coder, in an acute care
facility, required. Competent in the utilization of an electronic
medical record, and computerized coding/abstracting systems,
required. Experience with Computer Assisted Coding preferred.
Keywords: Northwell Health, New Haven , Him Coder- Union, Other , Riverhead, Connecticut
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