CODER EMERGENCY DEPARTMENT CDU

FLSA Status

Job Role Summary

This position exists to provide timely and accurate clinical coding and abstraction of Emergency Department (ED) services and Observation services for patients evaluated in the Clinical Decision Unit, to facilitate accurate reimbursement, research, and PI initiatives. This position is responsible for, but not limited to, facility coding, abstraction, and charge entry for the Emergency Department including, Center of Hope, and Trauma.

Essential Functions and Responsibilities

Leadership and Communication

• Proactively contributes to Eskenazi Health’s mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County. Models Eskenazi Health’s values of Professionalism, Respect, Innovation, Development and Excellence
• Supports departmental and organization-wide initiatives
• Communicates, coordinates, and collaborates with others

Service: Encompasses service to all customers served: patients, families, physicians, and community

• Interacts with physicians professionally and with courtesy
• Strictly adheres to the policies on Confidentiality of Patient Medical Records

Quality: Encompasses quality, performance improvement, and regulatory requirements 

• Identifies and assigns the appropriate primary diagnosis codes in accordance with coding guidelines and ED Coding standards.
• Identifies and assigns secondary diagnosis codes based on the specificity of clinical findings (i.e. laboratory, radiology, and pathology reports, as well as clinical studies) in support of existing clinical diagnosis. 
• Identifies and assigns the appropriate Evaluation and Management (E&M) code. 
• Identifies and assigns the appropriate Critical Care services code, when applicable.
• Identifies and assigns the appropriate procedure codes in accordance with charging guidelines and ED Coding standards.
• Identifies and assigns appropriate infusion and injections charges and accurately enters data into VIC. 
• Identifies and calculates appropriate observation hours ensuring all carveout time is reflected in the final total.
• Identifies and adds appropriate outpatient modifiers.  
• Follows grant specific guidelines to apply appropriate Center of Hope charges per ED Coding COH guidelines.
• Ensures Center of Hope modifiers are correctly applied to route to appropriate grant.
• Identifies and applies appropriate trauma activation charges per American College of Surgeons guidelines and ED Coding standards. 
• Analyzes ED documentation and CDU documentation to apply accurate coding and charge capture for the distinct and separate portions of the patients’ visit
• Identifies and comprehends key elements within provider and nursing documentation 
• Utilizes available resources appropriately to maintain quality and consistency in coding, abstraction, and charge entry processes.  
• Follows a defined process to query the medical staff for completion and/or clarification of documentation necessary to ensure coding compliance and accuracy 
• Maintains acceptable levels of performance related to productivity, accuracy, and quality standards
• Utilizes applicable software to retrieve documentation, abstract data/codes, and retrieve work lists. The identified systems include Epic, Allscripts VIC, 3M Encompass 
• Notifies ED management if inappropriate or unethical coding practices are identified or if there is uncertainty with legibility of the record, questionable, or unclear documentation

Job Requirements

• Registered Nurse with ED or Critical Care experience preferred.  Will consider non-RN coder with 2-3 years of experience and credentials (R.H.I.A., R.H.I.T., CCS, CCS-P, COC, or CPC).  If not credentialed, one of the above credentials will be attained within 2 years of hire.  
• Minimum of 2-3 years of coding experience utilizing ICD-10 CM, CPT, and HCPCS code classification systems is preferred.
   

Knowledge, Skills & Abilities

• Computer skills, and the ability to learn new skills quickly
• High level of concentration, self-motivation, attention to detail, and persistent follow-up
• Understanding of ICD-10 CM, CPT and CMS transmittals and changes with coding, regulatory and reimbursement requirements
• Requires ability to apply medical necessity coverage determinations as applicable, and seek coverage in the medical record documentation

Knowledge of:

• local Coverage Determinations (LCDs), Correct Coding Initiative (CCI) edits, APC grouping methodology, and the healthcare billing process
• medical terminology, anatomy and physiology, diagnostic and therapeutic tests, surgical procedures, and medical record documentation standards and retrieval
• E&M guidelines and assignment for emergency department coding positions