Overview

Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM and CPT-4 codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the director of Health Information Management, accurately code outpatient conditions and procedures as documented in the ICD-10-CM Official Guidelines for Coding and Reporting. Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors.

Responsibilities

- Utilizing all required electronic applications interprets and abstracts pertinent patient health information from documentation in the medical record. Identifies the principle, secondary diagnosis and procedures including complications and co morbidities. All coders are required to continuously maintain the required standards of their level. Level 1 Must code a minimum of 65 records per 7 hour shift with an accuracy rate of 95%.

- Be able to identify any discrepancies between the demographic and financial data. When necessary had to forward error cases to the manager, correct the patient disposition upon patient’s discharge.

- Exhibits a high degree of accuracy. Coder sequences the diagnosis and procedures using ICD-10CM and CPT-4 codes in accordance with the official Coding Guidelines and Hospital’s policy. Abides by Standards of Ethical Coding as set forth by the American Health Information management Association (AHIMA).

- Reviews with the manager when code assignments are unclear or documentation in the record is ambiguous or needs more clarification.

- Inputs all codes and other required data into the clinical information system for accurate APC, EAPG assignments. Identifies non-payment conditions (HAC) and when required, report through established procedures.

6. Describe responsibility:Must maintains Coding credentials by completion of educational programs that provide updated training and skills to allow continued competence in Coding by earning the required number of continuing education units.

- Abstracts from the medical record all required data and completes appropriate applications such as CAC tuning.

- Interacts in a professional, ethical and courteous manner with patients, visitors, and other BronxCare Health System staff. Behaves in a manner consistent with delivering the highest level of patient care and with maintaining and furthering a positive public perception of BronxCare Health System and its employees.

- Keeps abreast of coding guidelines and reimbursement reporting requirements. Participates in in-services and other training that is made available. Maintains up-to-date codebooks and references. Brings identified concerns/issues to the supervisor for resolution. Accurately completes in timely manner the tasks assigned by Supervisor.

- Establish and maintain positive relationships with patients, visitors, and other employees. Interacts professionally, courteously, and appropriately with patients, visitors and other employees. Behaves in a manner consistent with maintaining and furthering a positive public perception of BronxCare Health System and its employees.

Qualifications

- 1-2 Years Medical Records Coding experience

- CCS or CPC Required

- High school grad or equivalent.

- Medical Records Information Systems