Description
POSITION SUMMARY
Accountable for conversion of outpatient diagnoses and treatment procedures into codes using an international classification of diseases, and HCPCS codes based on documentation in the patient’s record, are coded accurately and in a timely manner. Complies with government, insurance regulations and with medical coding guidelines and polices that all records are coded accurately and in a timely manner. CORE FUNCTIONS
1. Reviews and validates all diagnoses/procedures stated by physician and other healthcare providers. Ensures that records are coded within 48 business hours of discharge. Notifies director whenever work is more than 48 hours behind work deadline. Meets productivity standard of assigning codes to a minimum of 25 charts per hour.
2. Partners with charting physician if diagnosis is not transcribed to assure all required documentation is presented to meet compliance accuracy in coding and severity of illness is charted and coded.
3. Codes diagnoses and procedures on based on documented information in the patient’s record that agree with physician’s preference 90% of the time. Will refer chart to director, if there is a question regarding the diagnoses/codes.
4. Utilizes computerized coding/abstracting equipment. 3. Codes outpatient for diagnoses/procedures in accordance with international classification of diseases and HCPCS coding principles and the Coding Manual 4. Meets quality standards of having 95% of diagnoses and procedures appropriately and/or correctly coded. Maintains 99% rate of information correctly abstracted.
5. Reviews coding periodicals within 7 days of receipt.
7. Maintains credential continuing education as per credential held
6. Abstracts all necessary information to accurately describe each documented diagnosis and procedure, following established HIM (Health Information Management) guidelines and the AHIMA
(American Health Information Management Association code of ethics.
Requirements
MINIMUM QUALIFICATIONS
High School Diploma or Associate’s Degree in Medical Records Technology or the equivalent in work experience. Knowledge of diagnoses/procedures in accordance with coding principles for both acute and clinical facilities. Knowledge of Medical Terminology & Anatomy and Physiology.
Be eligible to obtain CCS (Certified Coding Specialist), CPC (Certified Professional Coder) credential or RHIT (Registered Health Information Technician, RHIA (Registered Health Information Administrator) credential.
3-5 years of progressive Outpatient/Physician Coding Experience
Ability to use designated reference materials and able to work independently and prioritize workflow. Ability to work under pressure with time restraints and to concentrate in a busy office environment Excellent computer and data entry skills.
