Description

Coding Services assigns diagnosis and procedural codes for hospital outpatient (facility) medical records to support accurate reimbursement and data collection across the entire Ohio State Health System, including University Hospital, East Hospital, and The James Cancer Hospital. This position does not include professional-fee (pro-fee) coding.

ICD-10-CM and CPT diagnosis and procedure codes are applied to all hospital outpatients treated within The Ohio State Health System when services are not captured through the charge description master. Medical record abstract data is assigned based on a review of documentation for accuracy within IHIS during the coding process.

Position Summary 

The position is responsible for coding medical records and other documents at the conclusion of the patient’s visit. A senior medical records coding specialist requires the skill set to code multiple work types for outpatient services including: surgery, emergency department, clinics including oncology, and observation. This requires the selection of appropriate admitting diagnosis, principal and secondary diagnoses, principal procedure, and secondary procedures; assigning accurate ICD-10 and/or CPT-4 codes; sequencing the diagnoses and procedures codes; and abstracting information including admission source, type, disposition, admitting, attending and procedure attending physicians. 

Codes are selected in the Computer Assisted Coding/Encoder Software following review of information in the electronic medical record system, IHIS.  Information abstracted and coded is interfaced to IHIS Resolute Billing system. This staff member is responsible to address all edits or denials during the coding and abstracting process for complete and accurate coding for hospital reimbursement.

This staff member will maintain productivity and quality standards set for the department maintain an approved work schedule and submit a weekly volume log.

Organizational Expectations 

Practices within the Health System's policies and procedures. Adheres to the Medical Center’s values as demonstrated by striving for excellence, collaborating as One University, demonstrating integrity and personal accountability, openness and trust, promoting diversity in people and ideas, change and innovation, simplicity in our work, empathy and compassion, and leadership. 

Complies with the AHIMA Code of Ethics and Standards of Ethical Coding. Complies with the Department of Medical Information Management’s Standards of Conduct on Billing and Coding.

Minimum Qualifications for hire or promotion

For Hire:         

• Minimum completion of a CAHIIM-approved coding certificate program or HIMT program.
• Demonstrated coding proficiency through satisfactory completion of OSUWMC’s coding test.
• Familiarity or experience with computer-assisted coding and/or automated encoder.
• Minimum of 1-year outpatient coding experience (ICD10-CM and CPT) for service types such as emergency, outpatient, ambulatory surgery, observation, and series/clinics.
• For promotion: The ability to code at least four outpatient service types (ASU, observation, emergency, outpatient, and series/clinics).
   

Required:

Required for hospital coding: Credentialed as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) by the American Health Information Management Association; Certified Professional Coder (CPC), or Certified Outpatient Coder (COC).
 

Competency Expectations

Maintain continuing education requirements as determined by the American Health Information Management Association or American Academy of Professional Coders. Review Coding Clinics, CPT assistant as frequently as needed for education purposes, and to ensure the official coding guidelines are followed. 

The medical records coding specialist attends coding meetings and coding education sessions for updates on coding guidelines and related education opportunities.
 

Final candidates are subject to successful completion of a background check.  A drug screen or physical may be required during the post offer process.

Applicant Location

US residents only