Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
Applies the Uniform Hospital Discharge Data Set definitions as well as any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record.
Reports diagnoses and their associated Present on Admission Indicator (POA) and procedures in accordance with the established International Classification of Diseases 9 th Revision Clinical Modification (ICD-9-CM) Official Guidelines for Coding and Reporting.
Reports a discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.
Assigns and reports all other data elements required for (Statewide Planning and Research Cooperative System) SPARCS data collection.
For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.
Applies and adheres to Outpatient Perspective Payment System (OPPS), APC foundations and the use of Correct Coding Initiatives (CCI) edits during CPT procedure selection.
Logs all discharges into the computerized Discharge Log, enters specific data elements and assigns appropriate discharge physician.
Analyzes medical records for completeness of documentation and contacts physicians for clarification for any incomplete/ambiguous or conflicting documentation.
Assist in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, and re-sequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and occurrence of events.
Serves as an onsite resource for CPT-4 and ICD-9-CM coding concerns.
Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines, and regulations.
Demonstrates the correct use of the automated medical record tracking system.
Maintains the minimum data standards for accuracy and productivity as defined by the facility.
Performs related duties, as required.
High School Diploma or equivalent, required.
In Patient Coding: Certified Coding Specialist (CCS) credentials, required.
Out Patient Coding: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician, required.
Minimum of two (2) years prior coding experience in an acute care setting, required.
Thorough knowledge of ICD-9-CM, CPT-4, HCPCS, and DRG coding and classification systems, required.
North Shore-LIJ Health System - 3 years ago
One of the nation's largest health systems, North Shore-LIJ delivers world-class clinical care throughout the New York metropolitan area,...