What are the responsibilities and job description for the CODER position at COMMUNITY MEMORIAL HEALTHCARE, INC?
Health Information is looking for an individual to join their team to code.
The regular duties that are included in this position are:
*Accurately track all admissions/discharges (inpatient), including some outpatient for statistical purposes (i.e. daily census).
*Assist in chart assembly and perform chart analysis. Analyzes medical records of discharged patients for completeness and accuracy according to department and hospital policy and procedures.
*File completed charts and be able to retrieve charts.
*Maintain accurate medical record numbers.
*Ensure accurate transcription of medical records (history & physicals, discharge summary, operative reports, consultations, progress notes, etc.)
*Responsible for coordinating the release of medical information to all requesters, including patients, physicians, and other healthcare providers. Maintain a computerized log of all requests.
*Reviews medical record thoroughly to ascertain all diagnoses/procedures. Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record. Codes all diagnoses/procedures in accordance to ICD-10 and HCPCS coding principles and the Coding Manual. Refers medical record to Director, if there is a question regarding the diagnoses/codes.