Codes and abstracts inpatient accounts and outpatient accounts as needed. Assists with abstracting other outpatient accounts and coordinates the flow of medical records between the coding staff and the analysis staff as needed. Responsibilities Review and evaluate each medical record for appropriate assignment of ICD-10-CM diagnosis code(s).
Accurately identifies principle diagnosis and all secondary diagnosis. Review and evaluate each medical record for appropriate assignment of ICD-10-PCS procedure code(s), as applicable. Review and evaluate each medical record for appropriate assignment of CPT-4 procedure code(s) as applicable.
Abstract and enter accurately all information in both U. D. S. and Paragon.
Assist abstractors in the accuracy of the entries, notify supervisor of any problems with the data entry function. Review inpatient abstracting and correct errors. Evaluate selected DRG ensuring appropriate cc are captured if applicable.
Maintain professional rapport with physicians; contact physicians in questionable cases, suggest inservices, attend inservices given by physicians, ask questions, assist physicians in clarifying coding/clinical issues. Participate in coding audits/PI monitors to ensure quality of coding and abstracting. Work with Coding Manager to track/trend the data.
Work with the coding team to brainstorm and develop corrective action plans. Demonstrate the ability to utilize computer systems for maximum efficiency. Knowledgeable about menus and reports available through Paragon system.
Demonstrate ability to utilize all the software programs including U. D. S. and Paragon Qualifications/Requirements EXPERIENCE 1 or more years working in a Medical Records/HIM Department, Physician's office, or similar health care experience required.
EDUCATION High School Diploma or Equivalent required Associate's Degree in Medical Records Technology, Nursing, or other related field preferred LICENSES/CERTIFICATIONS Medical Terminology and Coding courses required Advanced Medical Terminology and Anatomy/Physiology and knowledge of automated coding/abstracting systems preferred Certified or working toward one or more of: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician (CCS-P) Certified Professional Coder (CPC), Certified Outpatient Coder (COC) Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (R.
H. I. A.).
OTHER Working knowledge of computer systems especially PCs and networked environments. Knowledge of alphabetical, numeric, and terminal digit filing systems. Ability to interact with all levels of hospital personnel especially the medical staff.
Basic administrative skills (filing, data entry, answering telephone) required.