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Medical Coding Specialist

Salary: $18.62-$22.73 hourly / $3,239-$3,954 monthly / Range: 5196

DEFINITION: Under general supervision, evaluates medical records and charge tickets to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual - Clinical Modification (ICD-9-CM), and the American Medical Association's Current Procedural Terminology manual (CPT); provides technical guidance and training on medical coding to physicians and staff; and performs related duties as required.

DISTINGUISHING CHARACTERISTICS: This is an advanced journey-level class. This classification is distinguished from the Medical Records Technician class series in that Coding Specialists code, evaluate the work of other staff, and develop and conduct staff training.

EXAMPLES OF DUTIES:

1. Evaluates medical record documentation and charge ticket coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the outpatient visit, and to ensure that data comply with legal standards and guidelines; interprets medical information such as diseases or symptoms, and diagnostic descriptions and procedures for a given visit in order to accurately assign and sequence the correct ICD-9-CM and CPT codes; reviews Medi-Cal and Medicare reimbursement claims before submission for completeness and accuracy and to minimize claim denial; evaluates records and prepares reports, on such topics as number of denied claims or documentation or coding issues, for review by management and/or professional evaluation committees; makes recommendations for changes in policies and procedures; assists data processing staff in making revisions to the computer master file as required.
2. Provides technical guidance to physicians and other departmental staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines; educates and advises staff on proper code selection, documentation, procedures, and requirements; identifies training needs, prepares training materials, and conducts training for physicians and support staff to improve skills in the collection and coding of quality health data.
3. Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation; develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and optimize revenue recovery.

EMPLOYMENT STANDARDS:

1. Possession of an Accredited Record Technician's certification (ART) or Certified Coding Specialist designation (CCS) issued by the American Health Information Management Association; or,
2. two years of experience in medical record coding; or,
3. equivalent combination of experience, education, and training that would provide the required knowledge and abilities.

Knowledge of: ICD-9-CM, and CPT coding guidelines; medical terminology; anatomy and physiology; Medi-Cal and Medicare reimbursement guidelines; English grammar and usage.

Ability to: research and analyze data, draw conclusions, and resolve issues; read, interpret, and apply policies, procedures, laws, and regulations; read and interpret medical procedures and terminology; develop training materials; make group presentations; train staff; exercise independent judgment; prepare reports and related documents; maintain working relationships with physicians and other staff; review the work of others; maintain confidentiality; influence/coordinate efforts of others over whom one has no direct authority.
 



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