Duke University Health System (DUHS) Job Descriptions

MEDICAL CODER SPECIALIST

Job Title: MEDICAL CODER SPECIALIST
Job Code: 4583
FLSA: N
Job Level: E3
Revised Date: 08/01/2024
Supervisory Responsibility:

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General Description of the Job Class

The Medical Coder Specialist will have frequent and daily interactions with internal and external clients including but not limited to Physician and Non-physician Surgical Providers. Responsibilities include primary diagnosis and procedural coding for the designated major surgical specialty areas and other major procedural areas including capture of applicable Physician Quality Reporting System (PQRS) and reconciliation of all surgical cases performed at each hospital where applicable. The Medical Coder Specialist focuses their work on the detailed physician surgical chart abstraction as well as being an immediate liaison to documentation improvement and optimization of physician coding practices for compliance and revenue purposes for the providers in these areas. Surgical abstraction coding is defined as identification of codes based solely on the source documentation for CPT and ICD-10-CM respectively.

Duties and Responsibilities of this Level

Primarily code from final surgical/procedural operative reports signed by the provider. Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions. Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures. Correlate information from "approved" supporting clinical documentation not limited to Pathology, Radiology and/or other Physician Consultations after review by the Attending Physician, wherever appropriate.

Provide education/training to physicians and other providers on coding and clinical documentation. Consult with and educate/train physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding. Provide real-time feedback to surgical/procedural providers as it pertains to proper coding and clinical documentation of services performed. Engage in provider/ department contact and education as the primary liaison for clarification of documentation and coding for defined surgical operative cases including documentation deficiencies.

Mentor and assists in training of other coders within the department. Participate in the development of coding policies and procedures as identified. Coordinate/mentor the work of designated coding employees to ensure quality and quantity of work performed through regular audits. Assist with research and development of presentation materials for continuing education programs for physician in their areas of specialization.

Interact with and provides high-level analysis of trends to Management, Revenue Managers and others about Coding related issues. Researches and identifies trends in unbilled accounts. Contacts appropriate personnel for clinical documentation inefficiencies. Coordinate quality reporting measures w/ providers and revenue managers / management (PQRS). Collaborate with appeal and edit coders to expedient resolution of accounts. Use authorized electronic media/ systems for Physician and Non-physician Clinician documentation, Coding Abstraction for each Surgical Procedure, Review of CCI Edits, LCD and NCD coverage.

Perform other related duties incidental to the work described herein.

Required Qualifications at this Level

Education

Bachelor degree in medical record administration or associate degree in medical record technology or one year coding diploma or courses in Medical Terminology, Anatomy & Physiology with extensive training in coding.

Experience

Requires four years of coding experience, with at least two of those years in surgical abstraction (physician or medical group in multi- specialty surgical practices, i.e., Cardiothoracic Surgery, Neurosurgery, General Surgery, Orthopedics, etc.).

Degrees, Licensure, and/or Certification

Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)

Knowledge, Skills, and Abilities

Extensive knowledge of coding surgical procedures, applicable modifiers in multi-specialty setting

Understands and apply appropriate Center Medicare Services guidelines to coding

Advanced ICD-10-CM & CPT-4 coding conventions

Anatomy and Physiology

Medical Terminology

Extensive DRG/APC reimbursement knowledge

Coding software familiarity

Effective written and verbal communication skills

Data entry/CRT

Distinguishing Characteristics of this Level

Code and abstract from Surgical Operative Notes while providing the primary communication w/ specialty surgical providers in the health system.

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The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

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Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.