U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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NATIONAL I H S CODER POSITION DESCRIPTION
G S-0675-7

I. INTRODUCTION
This position is located in a health care facility of the Indian Health Service. The purpose of this position is to interpret, analyze, and assign diagnostic and procedural codes. The coding function provides the primary source for data and information used in health care, promotes continuity of medical care, and ensures compliance with third party reimbursement policies, regulations and accreditation guidelines.

II. MAJOR DUTIES

  1. 1. Performs quantitative analysis by reviewing records to assure the presence of all component parts such as patient and record identification, signatures and dates where required, and the presence of all reports which appear to be indicated by the treatment rendered.
  2. Performs qualitative analysis by evaluating the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.
  3. Makes the final determination that medico-legal requirements of the record is complete, accurate, and reflects sufficient data to justify the diagnosis and warrant treatment and end results.
  4. Identifies inconsistencies, discrepancies and/or trends within the medical record and discusses with the appropriate medical, nursing, or healthcare providers, and recommends appropriate modifications to include medical necessity under the Correct Coding Initiative.
  5. Assigns and sequences a variety of codes including but not limited to I C D / C P T / H C P C S codes based on the medical record analysis. Assures the final diagnoses and operative procedures as documented by the provider are valid and complete. When multiple diagnoses and procedures are listed, assures the procedure is related to the proper diagnosis.
  6. Analyzes and abstracts information from the medical record to identify secondary complications and co-morbid conditions to assure appropriate assignment under the Diagnostic Related Group (D R G), Ambulatory Patient Classification (A P C) systems and other alternate resources.
  7. Analyzes provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct C P T / H C P C code.
  8. Provides ongoing education, updates and briefings for the medical staff, business office staff, and other health care providers on changing coding conventions, rules, regulations and guidelines.
  9. Performs audits in accordance with the facility Compliance plan and Performance Improvement study designs, which may include findings from provider documentation trends, coding peer reviews, and reimbursement denials. Provides reports of findings and feedback to parties involved.
  10. Assists in development and modification of facility coding policies and procedures.
  11. Maintains record confidentiality in accordance with the Privacy Act of 1974, Alcohol and Drug Abuse Patient Records, Freedom of Information Act and other pertinent federal regulations.
  12. May perform other duties as assigned.

III. F E S FACTORS

Factor 1. Knowledge required by the Position F L 1-4 550 points

  • Thorough knowledge of medical terminology, abbreviations, techniques and surgical procedures; anatomy and physiology; major disease processes; pharmacology; and the metric system to identify specific clinical findings, to support existing diagnoses, or substantiate listing additional diagnoses in the medical record.
  • Skill in correlating pharmacy, laboratory, radiology, treatments and results with diagnoses.
  • Extensive knowledge of official coding conventions and rules established by the American Medical Association (A M A), and the Health Care Finance Administration (H C F A) for assignment of diagnostic and procedural codes.
  • Extensive knowledge of classification systems and references such as the International Classification of Disease (I C D), Diagnostic Related Groups (D R G ’s), Ambulatory Patient Classifications (A P C ’s), American Dental Association (C D T -2), Current Procedural Terminology (C P T).
  • Knowledge of Health Information Management theory, principles, practices, techniques, concepts and policies to analyze the medical record and participate in performance improvement activities.
  • Thorough knowledge of medico-legal aspects of health information management.
  • Thorough knowledge of the Privacy Act of 1974 regulations and requirements regarding responsibilities for patient confidentiality.
  • Thorough knowledge of J C A H O, H C F A, Medicare/Medicaid, Office of Inspector General, and I H S policies to ensure the record complies with regulatory requirements.
  • Basic knowledge of quantitative and qualitative processes to analyze health information.
  • Skill in operating computerized data entry and information processing systems. Skill in data collection to compile and organize information for reporting and presentation.
  • Basic knowledge of Performance Improvement methodology to track, trend, recommend resolutions, and report on status of adverse or quality service.
  • Oral communication skills to conduct briefings and training classes.
  • Writing skills sufficient to prepare reports and other materials.

Factor 2. Supervisory Controls F L 2-3 275 points
The supervisor defines the overall goals and priorities and is available for guidance with unusual problems. The supervisor relies upon the coder’s knowledge, skills, and abilities to independently perform his/her assignments. The Coder initiates and follows through with assignments using established policies, instructions, and accepted practices in Health Information Management. The Supervisor periodically reviews the work for results, technical accuracy and conformity to Health Information Management policy and regulatory requirements.

Factor 3. Guidelines F L 3-3 275 points.
Guidelines include numerous facility policies; accrediting standards (for example, J C A H O, A A A H C); Federal and State laws, regulations, and policies; Indian Health Service policies and established health information procedures. Guides are general and do not cover all areas encountered in work performed such as cases involving new diseases, treatments, terminology or drugs. The Coder uses considerable judgement in adapting and interpreting the general guidelines for application to specific cases to decide the most appropriate course of action to take. This includes devising new procedures, adapting to new computer technology, and instituting coding and analysis changes.

Factor 4. Complexity F L 4-3 150 points
The Coder makes decisions regarding the proper assignment and sequencing of diagnoses and procedure codes by interpreting and analyzing a variety of medical documentation from different sources.
Decisions involve choosing alternatives when standard procedures do not address the situation and may involve contacting staff in other administrative and clinical departments to achieve acceptable solutions. This work involves analyzing and interpreting conditions and elements to correct complicated inconsistencies or discrepancies in the record.

Factor 5. Scope and Effect F L 5-3 150 points
Work involves performance of a variety of specialized analysis and coding functions that provide the primary source of data and information used in health care. The incumbent performs a variety of duties that directly impact the accuracy, documentation, timeliness and reliability of health information management services. The work impacts facility accreditation, quality of patient care, reliability of research data, appropriate levels of third-party reimbursement, Government Performance Results Act (G P R A) and O R Y X performance indicators.

Factor 6/7. Personal Contacts/Purpose Contacts F L 2B 75 points
Contacts are with physicians, nursing staff, business office staff, employees within the immediate organization or work unit, and representatives of various outside state and federal agencies such as Third Party Fiscal Intermediaries and State Peer Review Organizations (P R O). The purpose of the contacts is to exchange factual information and to coordinate work efforts and solve technical and policy problems.

Factor 8. Physical Demands F L 8-1 5 points
The work is primarily sedentary. There may be some walking or carrying of light items such as manuals or files. Good eye/hand coordination is required.

Factor 9. Work Environment F L 9-1 5 points
The work environment involves risks and discomforts of a patient care setting including exposure to communicable diseases, working with office machines and computers. The demand of computer terminals and keyboards for long periods of time may cause eye, shoulder and wrist strain. Work is performed in a smoke free office setting. There is adequate light, heat, and ventilation in work area.

Total points = 1485=G S-7

IV. OTHER SIGNIFICANT FACTORS:
May be required to work rotating shifts, evening, nights, weekends, and holidays.