HCA, Hospital Corporation of America Medical Office Coder in Fort Worth, Texas

GENERAL SUMMARY OF DUTIES:Contributes to the company’s mission, vision, and values by reviewing medical records documentation to select the appropriate diagnosis and procedure codes, sequencing, and assigning from the ICD-10-CM and HCPCS/CPT coding applications. Applies all appropriate coding guidelines and criteria for code selections and adheres to Company and HCA-ASD Coding Compliance Policies and Procedures for the assignment of complete, accurate, timely, and consistent codes for diagnoses and procedures.

SUPERVISOR: CBO Director, Center Business Office Manager/Supervisor, or designee (depending on where position is based) * *SUPERVISES: None

*CLASSIFICATION:* Non-Exempt and subject to review if designated as market/division Coder

DUTIES INCLUDE BUT ARE NOT LIMITED TO: · Codes outpatient surgery center(s) records in a timely manner, including the assignment of ICD-10-CM, E/M, Procedure Categories, modifiers (when applicable), and HCPCS/CPT procedure codes. · Resolves/clarifies codes and diagnosis with conflicting, missing, or unclear information by appropriately utilizing the query tool to get additional information from the Medical Staff as necessary. · Ensures that 3M encoder updates are processed timely/upon receipt to ensure use of the most current coding information. · Codes billing supplies and implants; furnishes completed coding information as necessary to bill cases. · Assists business office management with any special projects related to coding issues or questions that may include medical records audits and other coding/HIM support, as appropriate. · Collects data and prepares reports of findings. · Assists with preparation for accrediting bodies and/or State reviews. · Shares knowledge of the reporting and the disposition of medical records (statistical reports). · Guides others to follow the state standards related to the release of information from medical records and assists with determining the appropriate release of medical information. · Initiates physician queries in compliance with HCA-ASD guidelines/policies where appropriate. · Reviews all official data quality standards, coding guidelines, company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current. · Utilizes the complete medical record’s documentation in code assignment. · Consults with the business office management for assistance with resolving issues, as needed. · Meets all educational requirements as stated in HCA-ASD policies. · Practices and adheres to the Company’s/Code of Conduct/philosophy and its/Mission and Values Statement/.

· Cross trains and performs other duties as assigned based on business operational needs.


· Codes an average of 80-150 charts per day.

· Meets required education hours.

· Utilizes 3M coding software in coding process for each account**and/or Regs for assistance when unsure of proper coding.

BEHAVIORAL SPECIFIC EXPECTATIONS: · Supports and adheres to all company and Center policies and procedures. · Supports and adheres to HCA/Code of Conduct/, related Ethics and Compliance policies, and HIPAA requirements.

· Supports and adheres to personnel policies and programs which specify privileges and responsibilities of employment, including compliance with an adverse incident reporting system, quality improvement program, patient safety initiatives, and risk management program.

· Displays willingness to speak up about safety issues or change practices to enhance safety; asks for help when needed; enhances teamwork; follows the safety literature/policies.


· Coding Technical Skills –Regulatory coding (ICD-10-CM and HCPCS/CPT) and associated reimbursement knowledge.

· Organization– Able to work independently; proactively prioritizes needs and effectively manages resources and time.

· Communication– Communicates clearly, concisely and professionally.

· Analytical Skills– Demonstrates ability to critically evaluate and appropriately act upon information.

· Customer Orientation– Establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.

· InitiativeIndependently takes prompt proactive steps towards problem resolution.

· Decision Making– Identifies and understands issues, problems, and opportunities; compares data from different sources to draw conclusions; uses effective approaches for choosing a course of action or develops appropriate solutions; takes action that is consistent with available facts, constraints, and probable consequences.

· Contributing to Team Success–**Actively participates as a member of the Center’s team to move the team toward the completion of goals.

· Policies & Procedures– Articulates knowledge and understanding of organizational policies, procedures, and systems.

· PC Skills– Demonstrates proficiency in Microsoft Office (Excel, Word, Outlook) applications; knowledge of, or ability to learn, AdvantX – Accounts Receivable System, Smart, HOST and other systems as required. Demonstrates ability to type on PC keyboard.

· Other General Technical Skills

o Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly, use 10-key, and transcribe accurately.


· Registered Health Information Technician (RHIT) or Registered Health Information Administrators(RHIA) college degree preferred.

· Completed coursework in Human Anatomy & Physiology, Medical Terminology, Introduction to Coding (including ICD-10 and CPT) preferred.

· Successful completion of an ICD-10-CM training or certification curriculum; or if currently pursuing such, then completion of 50% or more of the curriculum to date with an expectation of finishing within 2 months after hire.

o Must provide certification from a recognized professional coding organization, transcript from an educational institution, or similar proof of successful completion (i.e., competency assessments).


· Minimum (2) years experience in outpatient coding and/or Health Information Management required.

· Minimum (1) year of experience in a medical office setting highly preferred. (i.e. ambulatory surgery center, hospital, doctors office) preferred.


· Coding certification from AAPC or AHIMA preferred.

· A certificate or transcript of completed ICD-10 training, received from former employer, professional society, academic institution, etc.

· BLS may be required as per facility standard.

PHYSICAL DEMANDS/WORKING CONDITIONS: This job requires prolonged sitting, some bending, stooping and stretching. It also requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, computer, photocopier, telephone, calculator, and other office equipment. Requires normal range of hearing/eyesight/voice projection to record, prepare, and communicate appropriately. Requires occasional lifting up to 50 pounds. Work is performed in an office environment. Work may involve dealing with angry or upset people and may be stressful at times.

Title: Medical Office Coder

Location: Texas-Fort Worth-Plaza Day Surgery

Requisition ID: 09441-84305