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- Thoroughly review, analyze, and interpret the entire medical record (electronic and hardcopy), including progress notes, consultation reports, physician orders, nursing notes, operative reports, pathology reports, radiology reports, laboratory results, medication records, other ancillary service reports, and the discharge summary to identify all diagnoses and procedures occurring/affecting the current admission.
- Apply knowledge of anatomy and physiology, disease process, pharmacology, to identify diagnoses and procedures documented in the medical record.
- Apply knowledge of the ICD-9-CM, ICD-10-CM coding system to translate identified diagnoses and procedures to codes for accurate reimbursement and data.
- Adhere to Official ICD-9-CM , ICD-10-CM Coding Guidelines when identifying diagnoses and procedures.
- Abstract information regarding congenital malformations for reporting to the Congenital Malformations Registry (CMR) as mandated by New York State.
- Utilize the Uniform Hospital Discharge Data Set Definitions (UHDDS) to select the principal diagnosis, principal procedure, and other relevant diagnoses and procedures.
- Utilize all available resources to assist coding and reimbursement to the facility, including the American Hospital Association’s (AHA) Coding Clinic for ICD-9-CM & ICD-10-CM, Faye Brown’s ICD-9-CM & ICD-10-CM Coding Handbook, electronic reference material available in 3M encoder, and institutional coding policies.
- Alert the Coding Compliance Managers when the medical record documentation requires further clarification.
- Use Webstrat encoder logic and grouper software to assign diagnosis and procedure codes and respective DRG. Utilize the clinical analyzer to assist in refining and focusing on reimbursement under the DRG payment system.
- Maintain and continually enhance and update coding skills and knowledge by participating in continuing education programs to support the effective application of ICD-9-CM, ICD-10-CM and coding guidelines to inpatient diagnoses and procedures. This is extremely important due to the fast pace of technological and clinical advances in the medical field and in retaining credentials.
- Abide by all Federal and state regulations, as dictated by CMS, Medicaid, and other third party payers regarding reimbursement for the facility.
- Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
- Maintain confidentiality of all patient records and medical and other information.
- High School education, associate degree preferred
- Minimum 2 - 5 years inpatient coding experience in acute care hospital
- Proficiency in the use of computers 3M or Optum Webstrat knowledge or other encoding system
- CCS or CPC required with completion of ICD-10-CM and PCS training transcript or certificate of completion.