Under general supervision, assigns diagnostic and procedural codes to patient charts of moderate to high complexity levels using ICD-9-CM and CPT, HCPCS and any other designated coding classification system in accordance with coding rules and regulations.
- Reviews medical records for the determination and accurate assignment of all documented diagnoses and procedures.
- Assigns and sequence codes based on medical record documentation.
- Assigns appropriate discharge disposition.
- Abstracts and enters coded data and designated quality management data for hospital statistical and reporting requirements.
- Communicates documentation improvement opportunities and coding issues (i.e., discrepancies, physician queries, etc.) to the appropriate personnel for follow up and resolution.
- Ability to code multiple types of services, moderate to complex cases. Experience coding for PPS hospitals (not critical access).
- Registered Health Information Technician (RHIT), or
- Registered Health Information Administrator (RHIA), or
- Certified Coding Specialist (CCS) or Certified Coding Specialist – Payer (CCS-P), and
- Minimum one year technical coding experience that includes all types of inpatient and/or outpatient cases
- Experience in computerized encoding and abstracting in a Windows-based environment preferred
- Strong analytical skills necessary to choose appropriate codes for moderate to complex cases while ensuring optimal hospital reimbursement, and to assist with the review of clinical information as requested.
- Interpersonal communication skills to function as a coding resource to internal and external customers, function as a resource to entry-level coders, and interact with physicians regarding medical record information
- Must protect and maintain the confidentiality of patient information and handle with discretion and integrity.
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