JOB
Under the direction of the Director of Health Information Management, Identifies and codes Newborns, Obstetrics, ER’s and outpatient records for the purpose of reimbursement, research, and compliance with Federal Regulations using the ICD-10-CM/CPT coding classification systems. Responsibilities Maintain confidentiality, protecting patient information at all times: minimum information necessary to those with right and need to know.
Conduct a thorough review of the documentation available in the record, and accurately assign the appropriate principle and secondary, diagnosis and procedures. Apply Current Procedural Terminology (CPT) coding convention & general guidelines published by the American Medical Association (AMA) for surgical and diagnostic procedure coding. Follow coding guidelines as specified by AHA Coding Clinic and hospital policy.
Commit to code assignment and data reporting in an unbiased, honest and ethical manner. Abstract patient data correctly and accurately complete all required elements in the electronic information system. Follow department policy and UHDDS abstracting guidelines, facilitating a positive outcome in the OSHPD error reports.
Ensure all pertinent documentation is available in the record for final coding and abstracting. Discrepancies identified upon review of the medical record, for example in the content and quality of the transcribed report, are addressed appropriately. Consult with medical staff members when necessary, for purposes of clarification of diagnoses and/or procedures.
Queries are formulated well; are clear, concise, and affect efficient assistance to the medical staff member for timely and accurate query response, complete documentation, and final coding. Perform as a liaison, assisting medical staff members through education and feedback to improve the quality of documentation within the body of the medical record. Follow department policy for prioritization of records to be coded, including STAT requests.
Consistently update coding status in the abstract module. Monitor un-coded records, taking initiative to resolve any issues and ensure timely abstracting and coding of data. Consistently files medical records as assigned and in strict terminal-digit order.
Accurately maintains and consistently utilizes the chart location system. Serve as a role model and provide mentorship, assisting in the professional development of the Coder and Coder I staff members. Effective communication: writes and speaks clearly and concisely, affecting positive and efficient assistance to all requestors.
Perform required tasks and other duties as assigned, while maintaining a positive attitude. Completes job duties in accordance with productivity requirements and quality standards. Promptly report equipment malfunctions to the appropriate personnel to order service as needed.
Inventory supplies needed to perform job duties and place order on a regular basis to ensure an adequate supply at all times. Initiate & participate in required and voluntary continuing education opportunities, enhancing professional growth and maintaining CEU’s required for certification and/or by department policy. Maintains current AHIMA certification.
Submits copy to Director in a timely manner. Other duties as assigned or required. Qualifications EDUCATION, EXPERIENCE, TRAINING Current RHIA, RHIT, or CCS coding certifications 1-2 years of coding experience in acute hospital setting Knowledge and application of ICD10 classifications, CPT-4 and HCPCS with an accuracy level of 95% Must be able to work in a very challenging environment.
Exceptional written and verbal communication skills Excellent computer skills, including Microsoft Office, EHRs, Encoders Analytical/critical thinking and problem solving Knowledge of information privacy laws and high ethical standards