St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

Codes and abstracts all pertinent patient medical information according to ICD-10-CM/PCS and CPT-4 coding conventions, UHDDS guidelines and CMS directives. Completes data entry of abstracted inpatient/outpatient diagnosis and/or procedure codes into Network’s health information system. Collaborates with the Health Information/Medical Records and Finance departments to ensure appropriate flow of information.

The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

PLEASE NOTE:  A 10-question coding skills assessment is a part of the SLUHN application process.  The following materials will be needed in order to complete the assessment:  INPATIENT – ICD-10-CM & PCS codebooks; OUTPATIENT – ICD-10-CM and CPT-4 codebooks.  Please plan your time accordingly.

JOB DUTIES AND RESPONSIBILITIES:

ESSENTIAL FUNCTIONS:

1. Codes and abstracts diagnosis and procedure information from patient medical records according to AHA ICD-10-CM/PCS and AMA CPT-4 coding conventions, UHDDS and CMS guidelines and regulations.   Utilizes the 3M Encoder to verify and assign ICD-10-CM/PCS and CPT-4 codes, and MS-DRG/APR-DRG assignment.

2. Maintains 95% data quality coding accuracy rate as measured through quarterly department quality reviews.

3. Maintains daily productivity and turnaround times as outlined in Department’s Performance Improvement plan (attachment A)

4. Responsible for remaining up-to-date knowledge of AHA ICD-9-CM/ICID-10-CM/PCS coding conventions, MS-DRG and APR-DRG principles and guidelines.  Maintains a working knowledge of prospective payment systems as it relates directly to coding process.

5. Participation in department and sectional meetings, education sessional sessions and workshops as scheduled.

6. Maintains working knowledge of clinical documentation improvement program and functions as liaison for RN clinical documentation specialists (inpatient coding professionals only).

7. Demonstrates/models the Network’s core values and customer service behaviors in interactions with all customers (internal and external).

8. Maintains confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.

9. Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.

10. Demonstrates/models the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external). 

11. Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.

12. Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.

13. Complies with Network and departmental policies regarding attendance and dress code.

OTHER FUNCTIONS:

1. Assists in training of new personnel      

2. Other related duties as assigned.

PHYSICIAL AND SENSORY REQUIREMENTS

PHYSICAL/SENSORY DEMANDS:  Sitting for up to 7 hours per day, 3 hours at a time. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Extended periods of vision use for reviewing and coding computerized patient records approximately 7 hours per day, 3 hours at a time.  Hearing as it relates to normal conversation.  Occasionally may be required to use upper extremities to lift up to 10 lbs.; stoop, bend, or reach to retrieve resource materials and/or paper records in accordance with department downtime policy..

POTENTIAL ON-THE-JOB RISKS:  No identified risks.

SPECIFIC PROTECTIVE EQUIPMENT AVAILABLE:  N/A

MOST COMPLEX DUTY:  Ability to apply objective understanding of AHA ICD-10-CM/PCS coding conventions and AMA CPT-4 guidelines.   Appropriately assign diagnosis and procedure codes for accurate reimbursement.  Understanding computerized health information system and encoding software systems