Education / Licensure / Certification:
Education: High school diploma or equivalent.
Classroom instruction in medical terminology, disease process, human anatomy and physiology, and ICD-9-CM/CPT-4 coding required.
Licensure/ Certification: RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), or CCS (Certified Coding Specialist) certification preferred.
Previous coding experience required, Oncology prefered.
An equivalent combination of education and experience may be considered
Coding and abstracting of medical information for billing and statistical purposes, and entering the information into a computerized database. Responsible for assigning ICD 9 CM and CPT 4 diagnosis and procedure codes on a daily basis, including the sequencing of comorbidities and complications and procedure codes that impact DRG assignment, Severity of Illness and Risk of Mortality statistics.
DUTIES AND RESPONSIBILITIES:
1. Accurately and efficiently assign ICD-9-CM and CPT-4 codes, utilizing 3M software, to code inpatient and outpatient records per established departmental standards by assigning appropriate DRG to inpatient records and APC to outpatient records.
2. Accurately abstract all necessary information into the computer system.
3. Accurately code established standard number of records per shift.
4. Review record to determine inpatient and outpatient status based on physician orders.
5. Act as liaison between medical staff, Health Information Management Department, and other departments by communicating all potential problems and/or suggestions from Medical Staff to Coding Supervisor or Associate Director.
6. Interact with medical staff on daily basis concerning documentation issues to ensure impact on DRG assignment, Severity of Illness and Risk of Mortality statistics.
7. Assist in ensuring all medical records are located for coding/abstracting on a daily basis by monitoring daily computerized discharge list.
8. Perform concurrent diagnosis and procedure coding on nursing units for Interim Billing as requested by Patient Accounting.
9. Report, according to procedure, any cases pertinent for Risk Management and Quality Assurance Departments.
10. Attach all loose paperwork, dictation, etc., to records before coding.
11. Assist in implementing new coding clinic rules.
12. Complete daily and weekly productivity sheet and submit to supervisor.
13. Attend mandatory in-service education programs and participate in appropriate staff development programs.
14. Employee will be held accountable for:
a. Performing job in cost-effective manner;
b. Maintaining work and work area in a neat and orderly manner; and
c. Adapting to changes in workload.
15. Demonstrate compliance to the health systems’ cultural behaviors, mission/vision, values, and commitments.
16. Perform other duties and responsibilities as assigned.
KNOWLEDGE, SKILLS AND ABILITIES:
1. ICD-9-CM and CPT-4 coding.
2. Required to pass the coding assessment administered by the HIM Department.
3. Thorough knowledge of software systems
4. Good decision making skills.
5. Ability to read proficiently at high school level.
6. Ability to read and analyze medical record contents.
7. Ability to sit for long periods of time.
8. Ability to bend and stoop.
9. Ability to lift and file records.
10. Good written and verbal communication skills.
Cone Health (formerly Moses Cone Health System) serves patients in central North Carolina through five acute and specialty care hospitals...