Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be utilized for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
Reviews the content of the medical record for hospital and professional inpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations.
Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes as required.
Using the Encoder software program, determines the codes for all diagnoses and procedures.
Determines their sequencing to legally maximize reimbursement.
Assigns the appropriate DRG.
Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines.
Queries physicians as needed to clarify documentation within the patient's record to facilitate complete and accurate coding.
Understands and applies internal policy and procedure guidelines regarding how to phrase physician queries.
Assists the Coding Quality and Professional Manager with training of new coding staff related to hospital and professional coding guidelines, encoder and other software systems needed for the coding process, along with reviewing coding guidelines on an annual basis and makes recommendations for change to improve coding and data management.
Communicates to Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc.
documented within patient records to ensure that appropriate diagnosis and procedure codes are selected and incorporated into hospital and professional coding guidelines.
Updates and corrects historical file data by completing and submitting claim action reports per the PHC4 quarterly report.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
*Relevant experience may be a combination of related work experience and/or completed specialty training program (1 year of specialty training = 1 year relevant experience).
Prefers DRG coding, familiarity of MDCs and knowledge /experience with ICD10-PCS
If a suitably experienced candidate cannot be found, applicants who meet the basic qualifications but possess fewer years of experience will be considered for hire at a lower level. Salary would commensurate with experience.
High School Diploma or Equivalent (GED)- (Required)
Minimum of 6 years-Relevant experience* (Required)
Certification(s) and License(s)
Registered Health Information Technician (RHIT) - American Health Information Management Association; Certified Risk Adjustment Coder - American Academy of Professional Coders (AAPC); Certified Professional Coder - American Academy of Professional Coders (AAPC)
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.