Under the general direction of the Director of Health Information Management and the direct supervision of the Coding Manager and within established policies and procedures, the incumbent performs the following functions:
Reviews the medical records of inpatient, ambulatory, and emergency department patients to determine the diagnoses that identify the condition(s) for the patient's admission. Lists diseases/conditions stipulated or evidenced by data within the current admission. Identifies procedures performed for definitive treatment. Assigns the exclusive code for diagnosis and procedure from ICD-9-CM or CPT-4. Ensures compliance with Uniform Hospital Discharge Data Sets (UHDDS) coding conventions and formulae and ensures integrity of indices, logs and registries generated. On Emergency Department and ambulatory patients, verifies charge master generated CPT codes. Seeks clarification from the attending physician in cases where documentation is absent, ambiguous or contradictory. Ensure tests ordered and performed are covered according to Medicare Limitations of Coverage/Medical Necessity manual and to ensure the appropriate APC/DRG is assigned. Educates the physician regarding DRG assignment or documentation requirements. Adheres to outside regulations and requirements, state reporting mandates. Provides coding to minimize the number of days in receivables. Communicates with Finance Dept. and clinical departments to resolve charge/coding issues as needed. Responds to requests for DRG changes and data entry corrections of specific data required by state, federal or departmental mandates. Maintains reference material on coding problems, updates or clarifications. Prepares daily assignments of records from previous day’s discharges. Answers telephone. Takes messages and distributes to appropriate person. Adhere to standards of coding/abstracting accuracy and timeliness. Ensures confidentiality of patient medical records and Catholic Medical Center matters.
Education: • High School Diploma. • Formal coding education preferred. • Medical Terminology, Anatomy and Physiology courses or equivalent, preferred. • Successful completion of Coder II Accuracy Test.
Experience: • Two years of Hospital Coding required.
Licensure: • CCS, RHIT, CPC preferred.