Individual responsible for coding all hospital inpatient records for purposes of reimbursement, research, and compliance with federal regulations. Applies correct ICD-9-CM diagnosis and procedure codes and assigns record to appropriate DRG.
Individual responsible for coding all hospital SDS records for purposes of reimbursement, research, and compliance with federal regulations. Applies correct ICD-9-CM diagnosis, procedure, CPT, and hospital modifier and assigns record to appropriate APC.
Key Responsibilities/Essential Functions
Reviews patient’s entire current medical record and assigns appropriate ICD-9 diagnosis, procedure, and CPT codes according to accepted coding guidelines and hospital’s policies and procedures.
Assigns accurate DRG and/or APC to patient’s record utilizing hospital encoding system.
Accurately abstracts statistical data from records using hospital abstracting system in accordance with hospital policies and procedures.
Attends hospital sponsored educational programs and department coding meetings.
- Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
- Performs compliance requirements as outlined in the Employee Handbook
- 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
High school/GED graduate, college-level courses in Coding. At least one year of acute care coding experience. Medical terminology knowledge, anatomy & physiology coursework preferred. Must be able to read, write legibly, speak, and comprehend English. Some computer or computerized encoder experience. 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. Must be able to perform the duties with or without reasonable accommodation. 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. 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.