Medical Records Coder Per Diem

POSITION SUMMARY

Reviews hospital medical records and/or reports to determine all diagnoses and procedures; assigns the correct ICD9-CM and/or CPT code; adheres to accepted coding conventions; accurately inputs information into Meditech for purposes of reimbursement and clinical and financial decision making.

KEY RESPONSIBILITIES

• Reads and interprets health record documentation to identify all diagnoses and procedures that affect the inpatient/outpatient stay/visit.
• Assesses the adequacy of health record documentation to ensure that it supports all diagnoses and procedures to which codes are assigned.
• Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to assign accurate codes to diagnoses and procedures.
• Applies knowledge of current approved coding guidelines (as published in Coding Clinic for ICD9-CM) to assign and sequence the correct diagnosis and procedure codes for hospital inpatient services with a 95% accuracy rate.
• Applies knowledge of current coding guidelines and regulatory agency guidelines to assign the correct diagnosis and procedure codes for hospital outpatient services with a 95% accuracy rate
• Applies knowledge of CPT format, guidelines and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly.
• Applies Uniform Hospital Discharge Data Set (UHDDS) definitions to select the principal diagnosis, principal procedure, complications and comorbid conditions, and other diagnoses and significant procedures which require coding.
• Applies knowledge of the Prospective Payment System to confirm DRG assignment which ensures optimal reimbursement.
• Refuses to fraudulently maximize reimbursement by assigning codes that do not conform to approved coding principles/guidelines.
• Applies knowledge of the Outpatient Prospective Payment System to confirm APC/APG assignment which ensures optimal reimbursement.
• Applies knowledge of ICD9-CM instructional notations and conventions to locate and assign the correct diagnostic and procedural codes and sequence them correctly.
• Attaches modifiers to procedure or service codes when applicable.
• Accurately codes for the professional vs. technical component when needed.
• Clarifies conflicting, ambiguous, or nonspecific information appearing in the record by consulting the appropriate physician.
• Participates in quality assessment to ensure continuous improvement in ICD9-CM and CPT coding and collection of quality health data.
• Demonstrates the ability to recognize potential coding quality issues from an array of data.
• Accurately enters data into Meditech, verifying any existing information.
• Participates in educational sessions for physicians and hospital staff on coding, reimbursement, and documentation rules.
• Orients, trains, and evaluates new coding staff
• Assists in the updating to the charge description master when needed
• Prioritizes coding functions to meet hospital time frames
• Conducts meetings for coding staff on a monthly basis

CUSTOMER SERVICE SKILLS:

• Is cooperative in interactions, treating customers with courtesy, respect and compassion.
• Is patient when responding to questions and answers questions appropriately
• Responds to requests in a timely manner
• Handles interruptions in a skillful way
• Manages a professional appearance and demeanor
• Strives to prevent/resolve customer concerns to the customer’s satisfaction.

REQUIRED KNOWLEDGE & SKILLS:

• Is responsible for ongoing development of his/her work skills through the use of available resources (i.e. in-services, formal educational programs, other work groups and on-the-job training).
• Attends and participates in staff meetings and in-services and/or reviews documentation as required.
• Assists in the orientation of others and actively participates in mentoring.
• Performs analytical and decision making functions with minimal supervision.
• Recognizes and seeks assistance/consultation when appropriate.
• Demonstrates an understanding of relative Hospital and all-departmental policies and procedures including safety issues.
• Possesses awareness of programs/services provided by Hospital and where they are located.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

Required Qualifications: Two to four years coding experience in a health care setting; working knowledge of ICD9-CM and CPT-4 coding systems and prospective payment systems.

Preferred Qualifications: Certified Coding Specialist or Accredited Health Information Technician credentials preferred. Inpatient coding experience preferred