Provides coding and abstracting services for the full range of hospital services and/or complex specialty practice areas. Reviews diagnosis and diagnostic information and codes and abstracts diagnoses and/or surgical procedures on all inpatient, outpatient and emergency room records using ICD CM and CPT 4 coding classification systems. Completes DRG and APC assignments on inpatient or outpatient record as appropriate. Ensures ethical and accurate coding in accordance with all regulatory requirements and AHIMA Standards of Ethical Coding.
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 or 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.
Acts as a knowledge resource to clinical staff in billing code matters. May provide leadership and training for less experienced staff members.
High school diploma/GED or equivalent working knowledge and specialized formal training in medical record keeping principles and practices, anatomy, physiology, pathology, medical terminology, standard nomenclature, and classification of diagnoses and operations, or an Associates degree in a health care field.
Requires Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCS-P) or Registered Health Information Technologist (RHIT) or Registered Health Information Administration (RHIA) in an active status with the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).
Must demonstrate a level of knowledge and understanding of ICD and/or CPT coding principles as recommended by the American Health Information Management Association coding competencies, and as normally demonstrated by certification by the American Academy of Professional Coders. Requires three or more years of experience providing coding services for a broad range of hospital and acute care facilities. . Must be able to achieve an acceptable accuracy rate on the coding test administered by the hiring facility according to pre-established company standards.
Must be able to work effectively with common office software and coding software and abstracting systems.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.