Position Summary

Under general supervision, this position is responsible for the following activities: application of the appropriate CPT and ICD-10 codes to individual patient medical records; review of medical record documentation for the elements necessary to determine the appropriate code assignment; and for providing feedback to the physician regarding documentation improvement opportunities.

Assigned codes are used for physician reimbursement and to establish a statistical database for the company. This database is used throughout the organization for administrative planning and to meet regulatory reporting requirements. 

Essential Duties and Responsibilities

Productivity /Efficiency

• Analyzes and evaluates medical record documentation to determine the appropriate CPT (E&M Level and procedure) codes and ICD-10 diagnosis codes that may be reported by the Client for billing purposes, according to current Brault policy, government regulations, and payer requirements. 
• Completes coding functions for all charts assigned daily and distributes coded charts to the subsequent step in the workflow according to Brault P&P and departmental protocols. 
• Reviews documentation for opportunities to improve physician documentation for services rendered, thus improving reimbursement. 
• Completes documentation deficiency data collection forms for tracking/trending and reporting purposes. 
• Completes incomplete documentation forms for use in querying the physician for additional information needed to code the account. 
• Identifies accounts that are non-billable and or missing. 
• Codes a minimum of 135-150 charts per day (18-20 per hour) with a 96% or greater accuracy 
• Delivers all work with one business days from the date the work became available to the coder. 
• Communicates all variations to the established workflow and escalates all issues that prevent daily coding or month end close. 
• Completes timecard and production records daily. 
• Participates in team activities for quality assurance and peer review as assigned. 
• Attends all departmental and company meetings. 

Technical Skills

Correct Coding Assignments:

• Maintains current knowledge of CMS regulations, ICD-10-CM guidelines, CPT coding standards, and Brault coding policies. Applies coding assignment in accordance with federal, state, and compliance regulations.
• Assigns correct modifiers, as appropriate. 
• Understands and applies rules regarding surgical packages. 
• Applies codes for other medical services such as X-rays, EKGs, etc. 
• Ensures coding and billing are based on medical record documentation according to the state and federal laws, regulations, Brault coding guidelines, and the OIG’s coding compliance work plan. 
• Ensures that all coded data is credible, reliable, and accurate reflections of the treatment provided to the patient. 

Communication

Consistently communicates with others with respect, kindness, and understanding; is honest and clear; treats sensitive information confidentially; is perceived as positive and demonstrates quality services. 

Quality

•  Applies correct codes at the rate of 96% accuracy for all service lines trained in. 
•  Ensures patient’s discharge status is accurate and complete. 
•  Escalates all problems with incomplete, missing, unbillable, clerical errors, late charts are appropriately and promptly. 
•  Ensures 100% on time coder close for each client. 

Adherence to Policy and Procedure

•  Adheres to all Company policies and procedures (i.e. Administrative and Human Resources), practices safe work habits, and engages in good business standards and practices. 

Other Job Functions 

•  Provides coverage datasets other than the primary client, to ensure on time close in the case of vacation, sick leave, etc. 
•  Accepts and performs other related duties and responsibilities as required upon request of the manager. 
•  Participates in in-services and continuing education activities. 

Knowledge, Skills, & Abilities

• Demonstrates extensive knowledge of disease entities and disease process, medical terminology, anatomy, physiology, medication purposes, and administration, and the purpose and definitions of common medical procedures.
• Demonstrates analytical skills, and the ability to translate documentation in various parts of a medical record into specific codes.
• The ability to work a fast pace and maintain a high concentration level with accuracy.
• The ability to effectively and tactfully communicate the relationship between coding and documentation with physicians.
• Demonstrates high proficiency in maintaining the quality and quantity of coding standards.
• Ability to work independently with minimal supervision, to work under pressure, and to work under deadlines.
• Computer keyboarding skills, and experience with MS Office.

Education & Experience Requirements

• Requires completion of a defined training program resulting in a CPC or CCS-P by an accredited institution (AAPC, AHIMA).
• Background in ED, Urgent Care, ICU and/or hospitalist coding preferred.
• Credentialed coders must have a minimum of three years of experience in evaluation and management and CPT coding.
• Excellent understanding of ethical coding, reimbursement and documentation compliance.
• Experience with Electronic Health Record systems (EHR), coding/billing platforms and Microsoft Office Applications