Responsible for the review and coding of inpatient and/or ambulatory surgery records utilizing ICD-10-CM and ICD-10-PCS or CPT coding guidelines and conventions for the establishment of diagnoses and procedures. The coded data is utilized for reimbursement, clinical care assessment, education, research, case mix and health care statistical reporting.
1.Reviews, analyzes and codes inpatient and/or ambulatory (outpatient) surgery records utilizing all prevailing coding guidelines and conventions for the establishment of diagnoses and procedures.
2.Queries physicians for clarification of documentation if required.
3.Participates in the documentation improvement process on conjunction with Coding management and leadership.
4.Consistently meets or exceeds coding productivity standards as per department policies.
5.Ensures compliance with CMS and other regulatory compliance guidelines.
6.Participates in continuing education opportunities as set forth by Coding leadership. Acquires continuing education hours to maintain certification(s).
7.Promotes and contributes to the collaboration between HIM in a positive manner and serves as mentors to junior coding staff.
8.Other responsibilities as required.
Education Requirements
Coding certificate, CCA. CCS (inpatient) or CCS-P (outpatient) certification preferred.
Experience Requirements
Minimum of 2 years inpatient/outpatient coding experience in acute tertiary care hospital
Proficiency in the use of automated coding and DRG/AOC grouping software.
Licensing and Certification Requirements (if applicable)
Name: Certified Coding Specialist (CCS)
Issuing Agency: American Academy of Professional Coders (AAPC)
Collective bargaining unit: SEIU 1199-MSH
SEIU 1199 at Mount Sinai Hospital, 183 - Medical Records - MSH, Mount Sinai Hospital