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 Permanentes organizational institutional Coding Guidelines.

• 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 requirements.


• 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 classification systems.


• 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 systems.


• 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 necessary.


• 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 Department.


• In concert with the Coding Department management staff, identifies departmental performance/quality improvement opportunities.


• 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 projects.


• 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 review findings.


• Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.


• Demonstrates knowledge of security of systems by not sharing computer logons.


• Other Duties: Acts as a resource person to other hospital departments regarding coding questions and issues.


• Other duties as assigned by supervisors.

Grade 715

• Must have at least five (5) years of continuous inpatient hospital coding experience within the last seven (7) years.

• 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.

• Registered Health Information Administrator OR Certified Coding Specialist OR Registered Health Information Technician

• 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/A