Req Number 001QK5
Job Category Coding
Reviews electronic and paper medical records to identify and apply appropriate diagnostic and procedure codes. Enters all clinical data into computerized abstract. Utilizes the 3M encoder to generate the Ambulatory Payment Classification (APC) code when required
Reviews all clinical records to assign ICD-9-CM and ICD-10-CM diagnosis and procedure codes.
Reviews emergency department records, and selects appropriate Evaluation and Management Level (E&M level). Identifies all charges on superbill, posts all CPT procedures and assigns ICD-9-CM and ICD-10-CM diagnosis and procedure codes.
Reviews all recurring and minor operative records to assign ICD-9-CM and ICD-10-CM diagnosis and procedure codes and CPT codes. Assigns modifiers when appropriate.
Assure coding accuracy and assignment of APC.
Uses hospital Electronic Medical Record (EMR) and electronic imaging system to review medical records.
Verifies registration patient type and location codes are appropriate based on type of service provided and registration guidelines. All discrepancies are reported to the Coding Manager or Admitting Department staff to correct.
Checks to assure charges are appropriate whenever a patient type and location code require correction. If charges are incorrect, reports to the Coding Manager or the Patient Accounts staff to correct.
Abstracts the coded information from all medical records into Meditech abstracting the same day the procedure is performed. Enters collected data that includes disposition, consultants, admission and discharge diagnoses codes, procedure codes, surgeon, time in operating room, Do Not Resuscitate (DNR), Code 7, restraint, etc.
Assures abstracts are completed accurately prior to finalizing the release of hospital bill.
Inquires with Physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes and follows up with Physicians until resolved.
Performs related duties, as required.
• High School diploma or equivalent, required. Bachelor’s Degree, preferred
• Minimum of one (1) year experience working in Health Information Management, preferred.
• Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification, preferred.
• Must be computer literate, proficiency with MS Office Software (Word/Excel/PowerPoint) and Outlook preferred.
• Ability to read, write and communicate in English required.