Job Description
Job Description
REQUIREMENTS :
- License / Certification : Must possess one of the following AAPC / AHIMA certifications : Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)
- Experience : Minimum of 1-2 years’ experience as an Inpatient Coder at an acute care or academic teaching facility required or successful completion of Inpatient Coding apprenticeship program.
- Proficiencies : Extensive knowledge of medical terminology, anatomy and physiology, pathophysiology, pathology and laboratory medicine, coding guidelines for ICD-10, CM, PCS, CPT, Modifiers, etc.
- Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures, and documentation including CMS guidelines.
- Proficient computer skills using MS-Word, Excel, PowerPoint, Outlook, Electronic Medical Records (EMR) systems including Paragon, eClinical Works, Computer Assisted Coding (CAC)
RESPONSIBILITIES :
- Reviews medical records to identify diagnoses, CPT procedures and PCS procedures relative to the patient’s encounter.
- Selects the principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition.
Ensures appropriate DRG assignment.
- Abstracts appropriate information from the medical record based on the guidelines provided by the hospital and after a thorough review of the medical record.
- Solicits clarification from the physician regarding ambiguous or conflicting documentation in the medical record using guidelines provided by the hospital.
- Ensure all coding complies with the ethical coding standards / guidelines and regulatory requirements.
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