HEALTH INFORMATION CODER

MS513 $44,637 - $80,434
Creation Date: 01/05/2024
Change Date: 01/01/2025

FUNCTION OF WORK:
To perform coding of health care records for the purpose of reimbursement, research and compliance with federal regulations according to diagnosis, operation, and procedure using ICD-9-CM and CPT-HCPCS classification systems.

LEVEL OF WORK:
Experienced

SUPERVISION RECEIVED:
Direct from a Health Information Supervisor or other higher-level personnel.

SUPERVISION EXERCISED:
None.

JOB DISTINCTIONS:
Differs from Health Information Specialist by the absence of auditing health records.

Differs from Health Information Supervisor by the absence of direct supervision.

CORE COMPETENCIES:
CORE COMPETENCIES HAVE NOT BEEN IDENTIFIED BY STATE CIVIL SERVICE FOR THIS JOB TITLE. MORE INFORMATION ON THE SCS COMPETENCY MODEL CAN BE FOUND HERE.

EXAMPLES OF WORK:
EXAMPLES BELOW ARE A BRIEF SAMPLE OF COMMON DUTIES ASSOCIATED WITH THIS JOB TITLE. NOT ALL POSSIBLE TASKS ARE INCLUDED.

Codes, classifies and indexes diagnoses and procedures for purposes of standardization, retrieval, and statistical analyses of inpatient health care records.

Codes diagnoses and operative procedures according to standard procedures; contacts respective physicians concerning classification of diagnoses which are not codifiable.

Applies definitions and guidelines to determine the principal diagnosis.

Performs Diagnosis Related Group (DRG) assignments utilizing automated grouper or decision trees.

Audits health data collection and processing activities (e.g., coding, indexing and statistics).

Justifies coding decisions.

Maintains control procedures to assure accuracy and completeness of coded information.

Assists medical staff in determining the right diagnosis and procedure by using the correct classification system.

Maintains current coding of all hospital discharge records and assists with special studies and statistics.

QUALIFICATION REQUIREMENTS:
MINIMUM QUALIFICATIONS:
One year of experience in patient coding; OR

Registration with the American Health Information Management Association as a Registered Health Information Technician (RHIT), a Certified Coding Specialist (CCS), or a Registered Health Information Administrator (RHIA).