Job Summary
Evaluates medical records, provides clinical abstracts and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines.
Essential Functions
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.
Minimum Qualifications
High school diploma/GED or equivalent working knowledge and specialized formal training equivalent to the two year certification course 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 related health care field.
Must demonstrate a level of knowledge and understanding of ICD and 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. Six months providing coding services within a broad range of health 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, coding software, and abstracting systems.
Preferred Qualifications
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC) in an active status or or Certified Coding Specialist-Physician (CCS-P) with American Health Information Management Association or American Academy of Professional Coders is preferred. Will consider experience in lieu of certification/degree. Additional related education and/or experience preferred.
Additional related education and/or experience preferred.
