Abstracts, sequences and assigns diagnosis and procedure codes to medical records of discharged inpatients, Day Surgery and Observation outpatients as required for reimbursement and maintenance of patient database.
Duties and Responsibilities
1. Abstracts, sequences and assigns diagnosis and procedure codes according to for ICD-9-CM coding conventions and Uniform Hospital Discharge Data Set (UHDDS) definitions. Assigns CPT-4 procedure codes following the appropriate guidelines. Assigns diagnosis related groups (DRGs) using specialized computer software. Generates a coding work sheet and files in the medical record as required by hospital department policy.
2. Performs specialized and technical coding and assists with review of billing rejection audits and case-mix/billing department questions.
3. Maintains up to date knowledge of regulatory and compliance issues related to coding, documentation and billing.
4. Follows-up on outstanding, uncoded and incomplete charts. Perform periodic quality control audits of work.
5. Assists with coder education and training, and conducts review of work done by new coders to assess quality and accuracy of coding.
6. Provides leadership to staff in decision-making and prioritization in the absence of area supervisor. Maintains awareness of the day-to-day activities and goals of the Coding Unit in meeting billing deadlines. Assists in training new personnel in coding procedures.
7. Responds to outpatient clinics' requests for ICD-9-CM diagnosis and CPT-4 codes via telephone hotline. Meets criterion to work the coding hot line, STAT coding and interim billing.
8. Assists researchers in identifying cases by diagnosis and/or procedure codes.
1. Work requires the level of knowledge typically acquired through completion of two years of occupationally specific education or an Associate's degree in Medical Records or a closely related field and 5-7 years hospital based coding experience.
2. Work requires in-depth knowledge of medical records coding utilizing ICD-9-CM and CPT-4 Coding conventions. Ability to organize and abstract health data for entry into databases and understand data/information use in the healthcare setting.
3. Working knowledge of health records, computer systems, Microsoft applications, data integrity, and processing techniques required. This includes but is not limited to: medical terminology, anatomy, physiology, pathophysiology, data entry, data display, and various grouping programs (DRGs, AP-DRG, and APR-DRGs).
4. Achieves a minimum of 80% accuracy rate on the pre-employment coding assessment.
5. Must be highly detail oriented, ability to remain focused, have good organizational, interpersonal and communication skills.
6. Work requires the analytical skills to resolve problems that require the use of basic scientific, mathematical, technical principles or clinical knowledge. Work requires ability to solve problems appropriately using job knowledge and current policies/procedures.
7. Work requires knowledge of the HIPPA rules and regulations pertaining to patient’s information and confidentiality. Active CCS, RHIT, RHIA, Credentialed by the American Health Information Management Association (AHIMA)
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