Reads and abstracts data from inpatient, Skilled Nursing Unit, Observation and Same Day Care patient medical records for all medical specialties at UHA. Assigns diagnosis and procedure codes based on current regulations and coding guidelines and in compliance with UHA Compliance Policy.
Essential Duties and Responsibilities: include the following. Other duties may be assigned.
A. Ensures all inpatient, Skilled Nursing Unit, observation and Same Day Care discharged records are abstracted and coded accurately for all medical specialties and sub-specialties at UHA. Uses current diagnosis and procedure coding guidelines, current Medicare teaching hospital requirements and UHA's Compliance Policy guidelines. Maintains knowledge of and uses various departmental guidelines.
Medical specialties at UHA include, but are not limited to:
B. Organizes loose material in medical record according to documented sections, i.e., staff notes, lab results, nurses notes, stress test results, pathology reports, x-ray reports, etc. Reads all necessary data and assigns all appropriate diagnosis and procedure codes, including procedures and Evaluation and Management codes.
C. Interprets medical data in the form of lab tests, x-ray reports, op-reports, EKG's, pathology reports, etc. Determines diagnostic and procedure coding for all services performed. Abstracts entire patient medical record, unless department has assigned abstracting duties to individuals within the department. Recognizes complications of procedures. Recognizes appropriate medications for various symptoms and side effects of medication.
D. Manages inpatient discharge abstracting processes through various daily discharge logs and weekly reports. Uses reports to locate all backlogged charts on a monthly basis for abstracting.
E. Provides abstracting coverage for the various departmental billing staff in the occurrence of vacations, illness or vacancies, backlog or at the request of the departments. May perform some duties of departmental billing process, such as entering charges, missing charge reports, etc., as needed.
F. May conduct workflow studies and make recommendations to the Manager, Charge Capture and Special Billing to be used in advising the department in which the study was conducted.
G. May perform outside audits at the request of insurance carriers. Performs audit to determine why billing was generated as it originally was, ensure proper documentation exists, etc. Determines various insurance guidelines are met. Prepares response to insurance carrier.
High school diploma or equivalent required and
Two years of medical coding experience required and Certification required at time of hire
If Certified Procedural Coder (CPC) certified, two years of experience in medical coding required.
If Registered Health Information Technician (RHIT) certified, one year of experience in medical coding required.
If Certified Coding Specialist – Physician Based (CCS-P) certified, no additional experience is necessary.
Previous clinical experience, as an RN, LPN or Medical Assistant, highly desirable and will substitute for medical coding experience. Previous medical office experience preferred.
Prior experience in medical coding desirable, will accept patient accounting/medical insurance billing experience. Knowledge of anatomy, physiology and medical terminology required. Working knowledge of federal and state laws pertaining to medical billing and coding required.
Certification, as follows, required at time of hire.
„P Certified Procedural Coder (CPC) or
„P Certification as Certified Coding Specialist--Physician-based or
„P Certification as Registered Health Information Technician (RHIT, formerly Accredited Records Technician (ART))
Continued employment contingent upon maintaining certification and mandated rate of accuracy. This position is required to maintain a 90% accuracy rate and is subject to random auditing of work performed.
Specialized Knowledge and Skills
Medical records and supporting documents must be analyzed for specifics regarding diagnosis, procedures and levels of daily care in order to optimize physician reimbursement without compromising any coding or Medicare regulation. Work is performed under tight time frames. Requires close attention to detail.
Medical terminology, anatomy, physiology, pharmacology course work or training required. Strong knowledge of Medicare billing regulations, general coding guidelines and UHA's Compliance Policy preferred.
West Virginia University Hospitals - 30+ days ago