High School Diploma/GED
CCS, RHIT or RHIA
Minimum of 3 years of experience
Summary: Validates APR-DRG assignments and severity level for accuracy of coding and complete documentation. Serves as liaison with Medical Record Technicians and Care Managers to ensure appropriate use of on-line queries for clarification of physician diagnosis/procedure documentation. Interacts with physicians to clarify documentation and/or responses to queries to ensure accurate coding for APR-DRG assignment. Audits outpatient records for accuracy of ICD-9-CM and CPT Codes and outpatient grouping system.
Principle Duties and Responsibilities:
Required Education: High School Diploma or equivalent
- Reviews inpatient medical record documentation to validate APR-DRG’s assigned and severity of illness level.
- Reviews outpatient medical records for accurate Icd-9-CM and CPT codes and accurate groupings.
- Provides education for inpatient and outpatient coders.
- Ensures accurate DRG assignments for Medicaid patients on 3808’s.
- Audits abstracts for accurate data selection.
- Serves as liaison with Medical Record Technicians and Care Managers to ensure appropriate use of on-line queries for clarification of physician diagnosis/procedure documentation.
- Interacts with physicians to clarify documentation for Outpatient records and/or responses to queries to ensure accurate coding for APR-DRG assignment.
- Participates in department and section meetings as required.
- Attends education conferences in order to maintain required credentials.
- Maintains knowledge of all new regulations and coding changes.
- Sequences ICD-9-CM diagnosis and procedure codes to ensure accurate APR-DRG assignment and accurate severity level.
- Analyzes case mix data for selection of records to be audited.
- Maintain the privacy and confidentiality of protected health information.
- Complies with the standards of conduct and CRP
- Performs other duties as assigned.
Required Certifications, Licenses, Registrations: Certified Coding Specialist ( CCS) or Registered Health Information Technicians ( RHIT) or Registered Health Information Administrators ( RHIA)
Required Experience: Three (3) years’ experience in an acute care inpatient/outpatient s urgery coding experience serving in a data management, coding management or coding auditing position. ICF-9-CM and CPT coding experience.
Saint Agnes Hospital - 2 years ago