Analyzes physician/provider documentation contained in assigned Emergency Department (ED) and Outpatient Observation health records (electronic, paper or hybrid) to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Accesses charge work queues and systems to assign ER and Observation charges if performed by HIM. May also require calculation of Observation hours if performed by HIM.
Utilizes encoder software applications, which includes all applicable online tools and references in the assignment of Internal Classification of Diseases, Clinical Modification diagnosis and procedure codes, and Current Procedural Terminology / Healthcare Common Procedure Coding System (HCPCS) procedure codes and all required modifiers.
Utilizes coding guidelines established by:
The Centers for Medicare/Medicaid Services (CMS) ICD-CM Official Coding Guidelines for Coding and Reporting, ICD-PCS Official Guidelines for Coding and ReportingThe American Hospital Association (AHA) Coding ClinicThe American Medical Association (AMA) for CPT codes and CPT AssistantThe American Health Information Management Association (AHIMA) Standards of Ethical CodingRevenue Excellence/Health Ministry (HM) coding procedures and guidelinesESSENTIAL FUNCTIONS
Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
Navigates the patient health record and other computer systems/sources in determination of diagnoses, reason for visit, procedures and modifiers to be coded and/or for APC assignment.
Codes Emergency Department and Outpatient Observation records utilizing encoder software and online tools and references, in the assignment of ICD, CPT, and HCPCS codes and modifiers.
Accesses charge work queues, systems to assign ER and Observation charges and hours, based on medical record documentation, if performed by HIM at a Health Ministry.
Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous documentation.
Communicates effectively with clinical staff, physicians and office staff regarding documentation issues or needs. Communicates with case management concerning Outpatient Observation documentation issues.
Works with HIM and Patient Business Services (PBS) teams, when needed, to help resolve billing, claims, denials and appeals issues affecting reimbursement.
Exhibits awareness of health record documentation or other coding ethics concerns. Notifies appropriate leadership for assistance, resolution when appropriate.
Utilizes EMR communication tools to track missing documentation or Outpatient queries that require follow-up to facilitate coding in a timely fashion.
Maintains current knowledge of changes in Outpatient coding and reimbursement guidelines and regulations e.g., new modifiers.
Consistently meets or exceeds coding quality and productivity standards established by Revenue Excellence/HM.
Maintains CEUs as appropriate for coding credentials as required by credentialing associations.
Performs other duties as assigned by leadership.
Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
MINIMUM QUALIFICATIONSCompletion of an AHIMA-approved coding program or an AAPC-approved coding program, or Associate’s degree in Health Information Technology or a related field or an equivalent combination of years of education and experience is required. Bachelor’s degree in Health Information Management (HIM) or related healthcare field is preferred.
Certified Coding Associate (CCA), Certified Procedural Coder Apprentice (CPCA), Certified Procedural Coder (CPC), Certified Outpatient Coder (COC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) is required.
Two (2) years of current acute care coding emergency department and observation or physician coding experience is required.
Current experience utilizing encoding/grouping software or CAC is preferred.
Ability to use a standard desktop/laptop, email and other Windows applications, if needed, Internet and web-based training tools preferred.
Strong oral and written communication skills. Ability to communicate effectively with individuals and groups representing diverse perspectives.
Ability to work with minimal supervision and exercise independent judgment.
Ability to research, analyze and assimilate information from various sources based on technical and experience-based knowledge. Must exhibit critical thinking skills, strong problem- solving skills and the ability to prioritize workload.
Excellent organizational and customer service skills. Ability to perform frequent detailed tasks and provide productivity standard driven results. Ability to adapt to change and be flexible with work priorities and interruptions.
Must be comfortable functioning in a 100% virtual, collaborative, shared leadership environment. with minimal supervision and able to exercise independent judgement
Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONSMust be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in physical or virtual environments that may be stressful with individuals having diverse personalities and work styles.
Must possess the ability to comply with Trinity Health policies and procedures.
Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.
Must be able to work with interruptions and perform detailed tasks.
If applicable, involves a wide array of physical activities, primarily standing, sitting and reading. Must be able to sit for long periods of time.
Must be able to travel to various Trinity Health sites as necessary.
If applicable, telecommuting (working remotely), must be able to comply with Trinity Health’s and the Region/HM Working Remote Policy.
The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.