Job Summary
Reviews clinical documentation and diagnostic results as appropriate to extract abstract data and apply appropriate ICD-9-CM / ICD10-CM / PCS and CPT 4 codes for reimbursement and external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and any other regulatory edits.
Code and abstract medical records of high complexity within the Primary Enterprise acute care facilities.
Essential Functions
Reviews medical records of high complexity to identify the appropriate principal diagnosis and procedure codes, all other appropriate secondary diagnoses and procedure codes.
Assign and present on Admission, Hospital Acquired Condition and Core Measure Indicators for all diagnosis codes.
- Facilitates appropriate MS-DRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines.
- Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and / or EMR in an on-site or remote setting.
- Reviews charges and Evaluation and Management levels.
- Demonstrates proficiency with Microsoft Office Applications and in using required computer systems with minimal assistance.
- Abstracts coded data and other pertinent fields in the hospital electronic health record.
- Ensures the accuracy of data input.
- Meets established quality and productivity standards.
- Facilitates peer review and training for all Acute Clinical Coders in the coding department. Provides support to management.
- Stay abreast of coding principles and regulatory guidelines related to inpatient and / or outpatient coding.
Physical Requirements
Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and / or at home environment.
Education, Experience and Certifications.
High school diploma or GED required; Bachelor's degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology required.
4 years coding experience in acute care setting required. Current RHIA, RHIT, CCS, CPC-H, CPC or CIC required plus a passing score on the Coding test.
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