Posted on: January 25, 2023
Under indirect supervision, the Lead Coder is regularly assigned
to lead, train, coordinate, and review the work of assigned coders
and/or others who need assistance, advice, instruction, training
and in-service education in coding and abstracting.In addition, the
Lead Coder is also expected to code inpatient and all categories of
outpatient services, diagnoses, procedures and conditions working
from appmpriate documentation in the medical record uhen assigned
or needed, using the appropriate coding classification system.
Classification systems include ICD-CM (PCS, CPI*, HCPCS as well as
odier specialty systems as requited by diagnostic and pmceduralAll
work must be performed in accordance with the rules, regulations
and coding conventions of the current ICD-CM//PCS official
guidelines for coding and repotting Coding Clinic published by the
American Hospital Association , the current ICD-CM/PCS code book,
CPT, CPT Assistant, CMS, NCCI edits, OSHPD, and Kaiser Permanente's
organizational institutional Coding Guidelines. -Essential
- Review Medical Records to identify diagnoses/procedures.
- In concert with Coding Department management staff, organizes
and prioritizes all work to ensure that records are coded in
timeframes that will assure compliance with regulatory
- Demonstrates an in-depth knowledge of diagnosis and procedure
coding, including sequencing of codes and present on admission
assignment in conformance with ICDCM/PCS, CPT, Uniform Hospital
Discharge Data Set, Medicare guidelines and other appropriate
- Demonstrates knowledge of anatomy and physiology to interpret
general medical classifications for coding discharge data including
the most complicated, involved encounters/cases.
- Assigns Codes
- Codes accurately and completely all diagnostic and operative
information and professional hospital E/M services from the medical
record using ICD-CM/PCS, CPT, and HCPCS coding classification
- Accurately selects the DRG for each inpatient case and reviews
DRG discrepancies to ensure the appropriate DRG assignment.
- Verifies and abstracts all required data elements from the
record as required for billing and data reporting.
- Corrects data as appropriate.
- Ensures that all data abstracted is consistent with guidelines
outlined by TJC, OSHPD, and CMS, regional and local policy.
- Serves as an expert resource for the coders and others with
coding questions and inquiries.
- Supports and mentors the coders and provides coder training as
- Medical Record Coding Review: -On a regular, scheduled basis,
performs ongoing review of selected inpatient and outpatient cases
to ensure correct assignment and sequencing of codes.
- Participates in quality improvement peer review for coding,
abstracting, and DRG/APC assignments performed within the Coding
- In concert with the Coding Department management staff,
identifies departmental performance/quality improvement
- Based on assessed and/or identified needs, conducts training
and in-service education for assigned staff and serves as an
experts on ICD/CPT/HCPCS and DRG/APC assignments, issues and
- Completion of Medical Records: Interacts with physicns to
clarify and accurately document patient diagnostic and procedural
information.Ensures the accuracy and integrity of coded and
abstracted data prior to coding completion and submission.Ensures
timely record availability by meeting established coding,
abstracting and peer review productivity and quality standards
specific to Coder Ills.Participates in medical record documentation
review to monitor physician compliance with regulatory requirements
i.e., Physician Review Project.In concert with appropriate
managers, may provide physician review and education based on
- Confidentiality/Security of Systems: Maintains and complies
with policies and procedures for confidentiality of all patient
- Demonstrates knowledge of security of systems by not sharing
- Other Duties: Acts as a resource person to other hospital
departments regarding coding questions and issues.
- Other duties as assigned by supervisors. -Grade 715Basic
- Must have at least five (5) years of continuous inpatient
hospital coding experience within the last seven (7)
- High School Diploma/GED.
- Demonstrated completion of classes in medical terminology,
anatomy, physiology, current CD-CM and CPT codin conventions and
disease process from an accredited program.License, Certification,
- This position requires certification as a Certified Coding
Specialist (CCS) or Registered Health Information Technician (RHIT)
or Registered Health Information Administrator (RHIA).
- Demonstrated ability to understand the clinical content of a
health record including complex cases and translate to coding.
- Must be able to communicate with physicians in order to clarify
documentation of diagnoses/procedures.
- Ability to demonstrate knowledge of and utilize reviewing
skills related to coding quality and compliance.
- Demonstrated ability to utilize principles and techniques of
health record/data quality assurance and abstracting Ability to
manage coding inventory.
- Achieve a minimum score of 85% on the Kaiser Permanente HIM
Coder Il test Coding Editor test Basic knowledge of and use of
computer and computer keyboard.
- Must be able to meet productivity and quality standards
established for the Lead Coder position.
- Must maintain current AHIMA credential and complete all
required Continuing Education (CE) units/hours Must abide by the
ANIMA and/or AAPC code of ethics.
- N/AJob Schedule: Job Category: Health Information
Keywords: Kaiser, Berkeley , Lead Coder, Other , Berkeley, California
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