Summary :

Codes and abstracts hospital medical records (including Inpatients, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department) for diagnostic and procedural coding.

Utilizes federal, state procedures / guidelines to assure accuracy of coding and abstracting and productivity standards.

Collaborates with medical staff and clinical documentation improvement (CDI) staff to clarify documentation.

Maintains performance in accordance with corporate compliance requirements as it pertains to the coding and abstracting of medical records, as well as Diagnosis Related Group (DRG) assignment.

Position Responsibilities :

Accurately reviews each record and knowledgeably utilizes ICD-10-CM, ICD-10-PCS, CPT-4, and encoder to accurately code all significant diagnoses and procedures according to American Hospital Association (AHA), American Health Information Management Association (AHIMA), Uniform Hospital Discharge Data Set (UHDDS) hospital specific guidelines and rules / conventions.

Records coded include Inpatient, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department. Sequences principal (or first-listed) diagnosis and principal procedures according to documentation found in the medical records and UHDDS definitions.

Accurately utilizes written federal and state regulations and written guidelines regarding definitions and prioritizing of abstract data elements to assure uniformity of database.

Records abstracted include Inpatient, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department. Verifies and / or abstracts required data into computer system according to procedure.

Utilizes equipment and processes appropriately, to ensure efficient coding and abstracting; utilizes the established downtime procedures as needed.

Participates in maintaining DNB and accounts receivable goal.

Maintains department level competencies. Participates in performance improvement activities.

Position Qualifications Required / Experience Required :

Minimum of two years inpatient records coding experience or equivalent.

Ability to perform functions in a Microsoft Windows environment.

Ability to be detailed oriented and perform tasks at a high level of accuracy.

Ability to make sound decisions.

Demonstrate good communication and team work skills.

Previous experience with an electronic legal health record system preferred.

Required Education :

High School Diploma or GED required.

Knowledge of Anatomy & Physiology / Medical terminology required.

Coding education preferred or equivalent in years of experience.

Training / Certifications / Licensure :

AHIMA Certification : Certified Coding Specialist (CCS) Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) preferred

Last updated : 2024-06-14