US:NV:Carson City Imaging Administration Full Time Standard Office Hours *This position is fully remote* Summary The Coding Diagnostician evaluates medical records, provides clinical abstracts and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines. Assigns and audits compliant, complete, and accurate APC's, ICD-9-CM diagnosis codes, CPT/HCPCS procedure codes, E/M facility level codes, and modifiers for the hospital outpatient and inpatient services to include Cardiac Catheterization, Lab, and Electrophysiology, along with the technical codes.
Works collaboratively with other members of the coding team to complete all essential responsibilities in a timely fashion to meet the quality, utilization, and financial needs of the organization. Qualifications A high school diploma or equivalent Minimum of one of the following credentials: AHIMA RHIA AHIMA RHIT AHIMA CCS Active membership of AHIMA Five years of previous hospital outpatient coding experience. Two years of previous experience auditing of outpatient accounts Preferred Associate’s degree at a minimum in Health Information Technology from an accredited program or previous hospital outpatient coding and/or experience.
Knowledge / Skills / Abilities: Demonstrate ability to perform the essential functions as outlined above Demonstrated knowledge of the Outpatient Prospective Payment System (OPPS) to ensure optimal APC assignment. Demonstrated knowledge and proper usage of UHDDS definitions, official coding guidelines, AHA Coding Clinic for ICD-9-CM and HCPCS, AMA CPT Assistant, and multiple regulations, standards, and requirements pertinent to clinical documentation, coding, and billing.
Demonstrated knowledge of reimbursement payer issues related to medical necessity, OCE, MUE and CCI edits.
Analyzes medical information from medical records. Accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements. Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes.
Provides thorough, timely and accurate assignments of ICD and/or CPT4 codes, MS-DRGs, APCs, POAs and reconciliation of charges. Abstracts clinical diagnoses, procedure codes and documents other pertinent information obtained from the medical record into the electronic medical records. Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations.
Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment. Provides quality assurance for medical records. For all assigned records and/or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards As assigned, compiles daily and monthly reports; tabulates data from medical records for research or analysis purposes.