E&M/Specialty Coder

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.




• Corrects data as appropriate.




• Review Medical Records to resolve Ingenix and HealthConnect Coding Edits.




• 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.




• Work Organization and Prioritization.




• 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.




• Completeness of Medical Record Data.




• 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