Under general supervision, reviews all physicians' entries and diagnostic test results on inpatient and bedded outpatient paper or electronic records to harvest, substantiate and specify final diagnoses and procedures. Codes diagnoses and operative procedures using ICD-9-CM. DRG, and CPTIHCPCS coding systems as a means of classification for use in research, statistical studies, and cost reimbursement. Keys and completes computerized medical record abstract.
Basic Requirements: Ability to read and write, understand and follow written and verbal instructions
Other Requirements: ability to interpret medical terminology and to code records utilizing ICD-9-CM, DRG and CPT/HCPCS coding systems as normally acquired through completion of two years health information technology program.
Two years experience as a coder in a hospital health information management department or approximately six to nine months on-the-job experience to become familiar with GRMC. Experience must include familiarity with medical record coding and abstracting procedures, knowledge of anatomy, medical terminology, ICD-9-CM, DRG CPT coding processes. Data entry and abstracting skills required. Minimum typing skills of 20 words per minute.
Experience with on-line medical records preferred.
Georgia Regents Medical Center - 18 months ago