Medical Records CODER - Local

Description

Job Summary: Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases/Current Procedural Terminology (CPT). Requires skill in the accurate sequencing of diagnoses/procedures. Ensures that records are coded in an accurate and timely manner.

Demonstrates   Competency in the Following Areas:

Ensures that records are coded in a   timely and accurate manner. The goal is to ensure the following record types   are coded within the requisite timeframes; Inpatient three (3) business days   and Outpatient five (5) business days post discharge.

Reviews medical record thoroughly to   ascertain all diagnoses/procedures are coded and sequenced correctly,   resulting in accurate DRG/APC assignment when applicable.

Contacts responsible physician in a   professional, tactful manner, if diagnosis/procedures are not present in the   medical record and generate queries for any diagnoses/procedures where   further clarification is required.

Serves as a backup for running a   report of outstanding uncoded accounts. This should occur a minimum of   weekly, if not more frequently.

Performs abstraction Arkansas Trauma   Registry, Stroke Registry, Inpatient Quality Reporting (IQR), Outpatient   Quality Reporting (OQR) and Inpatient Quality Incentive Programs (IQI)

Maintains a 99% accuracy in   abstracting, as required for reporting purposes.

Refers medical records to Lead Coder   for review, if there are questions regarding the diagnoses/procedure codes,   either in ICD-10 or CPT.

Utilizes computerized   coding/abstracting software.

Codes all diagnoses/procedures in   accordance to ICD-10-CM/PCS/CPT coding principles and guidelines.

Reviews and corrects errors in the   billing SSI Rejection Queue.

Adds and adjusts charges as needed.

Monitors organizational email and   other internal communication mechanisms.

Meets productivity and quality   standards requiring 95% accuracy in assignment of principal diagnosis and   secondary diagnoses/procedures both in ICD-10/CPT.

Cross training encompasses the coding   of all patient types beginning with outpatient. Inpatient coding starts with   the training for OB and Newborn cases and progresses to the coding of all   inpatients. The inpatient volume may not support all coders to be thoroughly trained in inpatient coding, so   those coders with the most experience and clinical knowledge should be cross   trained first.

Stays abreast of all coding changes   and updates.

Assists the Lead Coder or Director of   HIM with state requirements and reports as required.

Enhances professional growth and   development through participation in educational programs, current   literature, inservice meetings and workshops; shows responsibility for own   professional practice and ongoing education. Ensures all required CEUs are completed in order to maintain   AHIMA/AAPC credential(s).

Ensures data quality and optimum   reimbursement allowable under the federal and state payment systems.

Acts as a resource person to hospital   staff for coding and may provide education regarding coding changes/issues.

Must be familiar with all medical   record and coding requirements, including pediatric and geripsychiatric.

Maintains a good working relationship   within the department, other departments and medical staff.

Supports and maintains a culture of   safety and quality.

Performs other duties as assigned by   the Lead Coder or Director of HIM

Performs performance improvement   functions through data collection and documentation review.

Requirements

Professional   Requirements:

Adheres to dress code, appearance is   neat and clean.

Completes annual education   requirements.

Maintains   regulatory requirements, including all federal, state, local regulations and   accrediting organization standards.

Maintains patient confidentiality at   all times.

Reports to work on time and as   scheduled, completes work within designated time.

Wears identification while on duty,   uses computerized punch time system correctly.

Completes inservices and returns in a   timely fashion.

Attends annual review and department   inservices, as scheduled.

Attends 12 staff meetings annually,   or reads and returns all monthly staff meeting minutes.

Represents the organization in a   positive and professional manner.

Actively participates in performance   improvement and continuous