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Reports to the Manager, Coding & Records. Reviews, codes, and analyzes medical records in order to abstract relevant data from patient medical records into the on-line computer system. Assigns DRGs to Medicare, Medicaid, and other required payors. Determines DRG and APC assignment on outpatient and inpatient records. Maintains productivity and accuracy levels for the assigned job code.

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Reviews and analyzes discharged patient medical records to ensure all applicable patient data is available for coding and abstracting by:

• Checking the diagnosis and procedure to ensure accurate coding and sequencing as specified by established coding principles and guidelines, following AHA, AHIMA, and CMS coding guidelines for outpatient and inpatient records.
• Obtaining accurate and complete patient data through the review of the medical record, discharge summary, history and physical, consultation, progress notes, laboratory, radiology, operative and pathology reports.
• Coding all procedures on inpatient records (all payors) and outpatient surgical records according to ICD-9-CM Codes, CPT-4 or Physician E&M (Evaluation & Management) Level Code (as applicable).
• Referring questionable diagnoses and sequencing issues to the physician for clarification.
• Communicating with the Patient Accounts staff and coordinating with department Manager any questionable abstract or coding problems.
• Assigning ICD-9-CM Codes and completing a coding summary.
• Reviewing and evaluating error messages and all incompatible DRGs to the manager or coordinator for a second level review.
• Completing medical records for abstracting. Resolving any medical necessity related issues.

Completes medical record data entry duties by:

• Abstracting diagnosis and procedure codes into the Hospital computer system according to specified guidelines.
• Designating APC assignment on outpatient medical records.
• Assigning accurately, when applicable, a DRG or APC to Medicare, Medicaid and other required payor's records with the assistance of various computerized grouper software.
• Abstracting professional E&M codes, professional procedure codes, and technical component procedures into the Hospital computer system charging module according to specified guidelines.
• Accurate and timely entry of charges on ED and OBS charts according to guidelines if applicable.

Ensures accurate and up-to-date coding by:

• Quarterly internal and external auditing.
• Reviewing Coding Clinic and attending coding workshops to enhance coding skills.
• Billing software edits.
• For the coding of diagnostic reports, a productivity standard of 250 reports is to be met and medical necessity holds resolved (based upon an 8 hour work day).
• For the coding of inpatient, ambulatory surgery/observations and emergency records, one of the following productivity standards must be met (all include data entry and are based upon an 8 hr work day):
• Inpatient Records: Coder I (15-19)
• Ambulatory Surgery/Observation Records: Coder I (28-43)
• Emergency Records Facility Records: Coder I (50-69)
• Emergency Records Professional Records: Coder I (60-79)

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Completing other job-related duties and projects as assigned.

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of coursework in medical terminology, anatomy, physiology and comprehensive knowledge of ICD-9-CM and CPT-4 coding principles. Attainment of certification as either RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator), CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist-Physician), CPC (Certified Professional Coder), or CPC-H (Certified Professional Coder-Hospital) or CCA (Certified Coding Associate credentialing and maintenance of the certification is required. One year of coding experience is preferred.
• Non-Credentialed: CCCA (Certified Coding Associate) credentialing is required within two years of the start date and applicable for the position. Maintenance of the certification is required. Quality and productivity standards are the same as Level I.

Knowledge & Skills

• Requires knowledge of medical terminology, anatomy and physiology necessary to code patient medical records utilizing established but specialized technical coding processes.
• Requires knowledge of the fundamentals of DRG assignment and optimization.
• Requires knowledge of state and federal regulatory guidelines for reimbursement in the prospective payment system in order to interface with physicians.
• Requires the analytical skills to compile and process patient information abstracted from patient records.
• Requires familiarity with computer data entry.
• Requires accurate typing skills of at least 40 w.p.m.
• An accuracy rate of 92% for inpatient and outpatient records is required for the Level I and II position. An accuracy rate of 95% for inpatient and outpatient records is required for the Coding Specialist position.
• Demonstrates the interpersonal and communication skills (both verbal and written) necessary to interact with staff, physicians, and others.

Working Conditions

• Works in an office environment.
• May experience some mental/visual fatigue from careful and constant review of records, code books, and continued use of computer equipment.

Physical Demands

• Requires the physical ability, motor coordination and stamina to perform the essential functions of the position.