Naval Outpatient Coder Job in San Diego, California Us

Performs a variety of administrative functions associated with health information including

·         Evaluates medical record documentation and charge ticket coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the inpatient or outpatient visit

·         Interprets medical information such as diseases or symptoms, and diagnostic descriptions and procedures for a given visit in order ensure completeness, accuracy, and compliance with the International Classification of Diseases and Operations Manual - Clinical Modification (ICD-9-CM), and the American Medical Association’s Current Procedural Terminology Manual (CPT) and Healthcare Common Procedure Coding System (HCPCS).

·         Responsible for coding Professional Services rounds and creates any additional RNDS encounters needed to capture professional services rendered on a given day, in accordance with Industry Based Workload Assignment.

·         Assigns ICD-9 CM codes to each diagnosis and procedure, following the guidelines provided by (AMA) Coding Clinic and Department of Defense (DOD), and Center for Medicare/Medicard Systems (CMS), and record codes into CHCS

·         Ensures accuracy and completeness of patient demographics and abstract medical records information, discharge status, diagnosis(es), complications and procedures documented

·         Interacts with appropriate personnel to clarify and accurately document patient diagnostic and procedural information.

·         Assign appropriate codes to patient records according to ICD-9-CM or other coding schemes to defined diagnoses and procedures

·         Ensure data comply with legal standards and guidelines;

·         Data-enter codes and other study related data utilizing computer software

·         Meet or exceed project-specific quality standards and production rates for coding and data entry

·         HIPPA compliant

·         Under general supervision, organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements

·         Contract employees shall apply appropriate coding classification standards and guidelines to medical record documentation for accurate coding

·         Shall resolve medical record documentation deficiencies through healthcare provider query

·         Shall provide routine feedback to healthcare providers to correct deficiencies. 

·         The contractor employees shall work as part of a team to perform medical record coding

·         Research errors or missing documentation

·         Interact with the providers, business managers or other Government personnel and Contract employees. 

·         Contract employees shall comply with the MHS timeliness standards stated below:

-          100% of all ambulatory patient encounters shall be coded within three business days of the patient encounter.

-          100% of APVs shall be coded within 15 calendar days of the procedure.

-          100% of all inpatient medical records shall be coded within 30 days post-hospital discharge.

-          Inpatient Professional Services (IPS) records shall be coded according to MTF standard operating procedures. 

·         The contract coder shall perform quality assessment of records, including verification of medical record documentation (both electronic and hand written), and shall provide the department head and individual providers with timely and regular feedback.

·         Contract coders shall perform the following duties in support of the coding function.

-          Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient

-          Advises members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management

-          Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed

-          Work with the MTF clinical champions, AHLTA Sustainment Trainers/Consultants, directors and department heads (to include Head, Staff Education and Training) to provide educational and consultative services for the development of best practices for outpatient and inpatient coding.  

·         Medical Record Coding Performance - Accuracy.  The acceptable accuracy rate for coding is 95%.