Under direct supervision, the E&M/Specialty Coder is responsible for accurate coding of professional services (diagnoses, conditions and procedures) from medical record documentation in a hospital setting. Working from appropriate documentation in the medical record, assigns codes and modifiers with ICD-CM, CPT and HCPCS Level II codes.  
All work is performed in accordance with the rules, regulations and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD and Kaiser Permanentes organizational and institutional coding guidelines.

• Review Medical Records to identify diagnoses/procedures.
• Under supervision, codes all diagnostic and operative information from the medical record using ICD-CM, CPT and HCPCS coding classification systems.  
• Verifies and abstracts all medical data from the record to assign appropriate codes for the following settings: Inpatient Hospital (IP), Hospital Emergency (ED), Hospital observation (HOPS), Hospital Ambulatory (HAS) Hospital Outpatient (HOV) and Medical
  • Office.
  • E&M/Specialty Coder may require specialty coding and will remain part of the responsibilities as long as business dictates.
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  • Corrects data as appropriate.
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  • Review Medical Records to resolve Ingenix and HealthConnect Coding Edits.
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  • Under supervision, identify and resolve coding related edits by reviewing the medical record and ensuring that all data and codes are consistent with ICD-CM Official Guidelines, CPT, CPT Assistant, CMS, OMFS, MediCal, USDOL, as well as KP Regional and Local policies.
  • Corrects data as appropriate.
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  • Work Organization and Prioritization.
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  • Under general supervision, organizes and prioritizes all work to ensure that records are coded, and edits are resolved, in a timeframe that will assure compliance with regulatory, billing and SOX requirements.
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  • Completeness of Medical Record Data.
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  • Under general supervision, interacts with clinical contracts to clarify and promote accurate documentation of patient diagnostic and procedural information.
  • Enters patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted or encounter
  • data corrected, prior to submitting the data.
  • Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the E&M/Specialty Coder position in the current Coder Work At
  • Home agreement.
  • Provides feedback to monitor service provider and line of business compliance with regulatory requirements.
  • Confidentiality / Security of Systems Maintains and complies with policies and procedures for confidentiality of all patient records.
  • Demonstrates knowledge of security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
  • Other Duties: Answers the telephone promptly and identifies themselves and the department.
  • Acts as a resource person to other departments regarding coding questions and issues.
  • Performs other duties as assigned.

Grade 594