Responsible for abstracting and coding inpatient and outpatient visits for all MWPH locations; responsible for submitting accurate quarterly data to Health Services Cost Review Center (HSCRC); and responsible for working with doctors and clinical staff to improve clinical documentation as needed for accurate coding; responsible for creating reports for internal use and for research; acts as backup for the Health Information Technician when needed and other tasks as needed.
ESSENTIAL FUNCTIONS OF POSITION
· Accurately abstracts and assigns diagnostic and procedure codes for inpatient and outpatient record.
· For inpatient records, enters final codes into Meditech within 15 days of discharge.
· For outpatient records, accurately abstracts and codes and enters into Meditech within 15 days after service date.
· Assigns admitting diagnosis code (ICD-9-CM) for all inpatients within 24 hours of patient’s admission – codes are assigned by end of day Monday for Friday admissions.
· Queries physicians and clinicians as needed to clarify their documentation of the patient’s conditions. Works to educate them about documenting appropriately for a patient’s condition and treatment.
· Is knowledgeable on sequencing final codes to include secondary and tertiary diagnoses (for complications and co-morbidities) so reimbursement is optimized.
· Keeps up to date on coding standards, issues, and practices. Researches and keeps abreast of appropriateness of code usage and code changes as needed for payment and for special services and patient groups seen at Mt. Washington .
· Works unbilled report in timely manner; keeps unbilled claims at a manageable dollar amount.
· Keeps up on required information to be abstracted from inpatient/outpatient records as required by HSCRC. Sends this information to HSCRC so it meets quarterly deadlines. Researches and corrects errors in Meditech to keep HSCRC error rate low.
· Works with Information Services as needed to keep IS coding databases current.
· Works with patient billing and finance to ensure accounts are coded accurately and timely so bills are processed promptly. Also provides backup to the Health Record Analyst as needed.
High School Diploma required. Medical terminology. College coursework required in Health Information Technology/Management and/or completion of ICD-9-CM and CPT coding courses.
Licensure, Certification and Registration
Registered Health Information Technician (RHIT) or Registered Health Information Manager (RHIA) or Certified Coding Specialist (CCS).
Work Orientation and Experience
Minimum of three years experience coding inpatient (acute care). Additional experience with Outpatient coding preferred.
Knowledge, Skills and Abilities
Knowledge of medical terminology, anatomy & physiology, ICD-9-CM and CPT coding systems. ICD-10 training is a plus. Computer skills required. Ability to communicate effectively with the clinical and medical staff. Ability to work under deadlines.
Other Requirements Specific to Assigned Area
Knowledge of Meditech is a plus.