Summary

Job Summary: Performs the process of coding and abstracting all patient medical records in accordance with established ethical and clinical coding rules and regulations. Responsible for accuracy of data in the abstract to ensure compliance with regulatory agencies and AHS procedures. Queries physicians for clarifying information when assigning diagnoses. Performs related duties as required.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification

1.  Codes all diagnostic and operative information from the medical record using ICD-9- CM/ICD-10-CM, CPT and HCPCS level 2 coding classification systems for ED, Trauma, Outpatient, Newborn, Normal Deliveries and non-acute care, including acute care rehab, behavioral health facility, and SNF.

2.  Completion of Medical Records; interacts with physicians to clarify and accurately document patient diagnostic and procedural information.

3.  Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM/ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.

4.  Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated encounters/cases.

5.  Enters patient information into the computerized inpatient and outpatient medical record and databases, ensuring the accuracy and integrity of the medical record abstract or encounter data prior to transmitting case. Ensures timely record availability by meeting coding and abstracting productivity / quality standards established for Coders I and II. Participates in medical record documentation auditing to monitor physician compliance with regulatory requirements.

6.  Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions. Organize and prioritize all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.

7.  Review medical records to identify diagnoses/procedures in assigned area of responsibility.

8.  Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment. Verifies and abstracts all medical data from the record to complete a data abstract on hospital encounters. Corrects data as appropriate.Ensures that all data abstracted and/or coded are consistent with guidelines outlined by regulatory, regional and local agencies.

QUALIFICATIONS: Education: Associate's degree preferred. Education: Completion of classes in medical terminology, anatomy and physiology, ICD-9/10 and CPT coding conventions, and disease process from an accredited program. Education: High school diploma or GED equivalent. Minimum Experience: One year hospital experience in coding within the past three years. Preferred Licenses/Certifications: Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT). Required Demonstrated Proficiency: Basic Computer Skills –passing score of 80%. Required Demonstrated Proficiency: HIM Knowledge –passing score of 80%. Required Demonstrated Proficiency: Medical Terminology –passing score of 80%. Required Demonstrated Proficiency: Typing/Data Entry -45 words per minute. Required Licenses/Certifications: Certified Coding Associate (CCS-P) or Certified Coding Apprentice (CCA) or Certified Professional Coder (CPC), or RHIT (Registered Health Information Technician), or RHIA (Registered Health Information Administrator).