Abstracts clinical information from medical records. Primarily assigns appropriate ICD-9-CM codes on inpatient accounts but when necessary, will assign appropriate ICD-9-CM codes and CPT-4 procedure codes to outpatient accounts.
Accuracy: Accurately codes all diagnoses and procedures. Measured by Coding Quality Audits: 97 percent of all records for which the employee is responsible must be coded accurately to maximize DRG/APC weight.
Inpatient coding: 20 minutes/record
Same Day Surgery/Observation coding: 12 minutes/record
Laboratory/Radiology coding: 2 minutes/record
Provider Office Visits: 2 minutes/record
Recurring Patient Visits: 3 minutes/record
Emergency Department coding: 5 minutes/record
A. Certified Coding Specialist.
B. Minimum of 2 years hospital coding experience, preferred.
C. Assigns ICD-9-CM and CPT-4 codes in accordance with coding and reimbursement guidelines including, but not limited to, the following:
1.Identifies principal and secondary diagnoses and procedures based upon UHDDS standards.
2.Uses fifth digit and sequencing conventions.
3.Documentation is present to substantiate codes assigned.
D. Abstracts relevant clinical and demographic information from the medical record.
E. Maintains a control system to assure completeness of the indexing system; enters all corrections in response to system edits and internal controls. Serves as a coding resource for the Patient Financial Services Department.
F. Refers coding and system questions to the Director/Supervisor in a timely manner for determination and guideline development.
G. Assists in abstracting and retrieval of data for selected studies requested by Clinical Excellence.
H. Keeps current on coding guidelines, rules and regulations, and new codes.
I. Other duties as assigned
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