Individual responsible for coding all Coder I work types ( clinical, recurring, referred) plus two of the following work types (at least 60% of the time). ER, Wound Care, Observations, and Pain management (Spine Care). Applies ICD-9-CM diagnosis and/or ICD-9 and CPT procedure codes and assigns record to appropriate APC for the purpose of reimbursement, research, and compliance with federal regulations. Coder must abstract statistical data from records into hospital abstracting system in accordance with hospital policies and procedures. Individual must have knowledge of APCs, federal and state coding guidelines.
Key Responsibilities/Essential Functions
Reviews patient’s entire current medical record and assigns appropriate ICD-9 and CPT codes according to accepted coding guidelines and hospital’s policies and procedures.
Assigns accurate APC to patient’s record utilizing hospital encoding system and correcting any edits flagged by that system.
Accurately abstracts statistical data from records using hospital abstracting system.
Attends hospital sponsored educational programs and department coding meetings.
- Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
- Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
- Requires use of electronic mail, time and attendance software, learning management software and intranet.
- Must adhere to all DCH Health System Policies and Procedures
- All other duties as assigned
Minimum Knowledge, Skills, Experience Required
Associates or bachelor’s degree in Health Information Technology or related field or a minimum of three years of hospital coding experience. RHIA, RHIT or CCS preferred. Medical terminology knowledge, anatomy & physiology coursework preferred. Must be able to read, write legibly, speak, and comprehend English. Some computer or computerized encoder experience required. Ability to maintain confidentiality absolutely required.
Requires ability to work 8 hours quietly at a computer screen and keyboard/mouse. Requires ability to withstand pressures of constant deadlines, audits, educational demands and changing healthcare environment. This job involves standing, walking, sitting, stooping, pushing, pulling, and crouching. Ability to lift up to 20 pounds occasionally and 10 pounds frequently. Must have good dexterity. Should be able to reach and extend arms in any direction. Hearing and vision must be normal or corrected to within normal range. Able to perform the duties with or without reasonable accommodation. Must be able to meet deadlines as assigned. Ability to communicate verbally. Ability to maintain confidentiality. Must be able to adapt to changes in work area as assigned.