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About the Role
Codes and abstracts hospital medical records (Inpatients, Same Day 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 to clarify documentation.
Maintains performance in accordance with corporate compliance requirements as pertains to the coding and abstracting of medical records, as well as DRG assignment.
Position Responsibilities:
Accurately reviews each record and knowledgeably utilizes ICD-10 and CPT and encoder to accurately code all significant diagnoses and procedures according to AHA, AHIMA, UHDDS hospital specific guidelines and rules/conventions.
Records coded include Inpatients, Same Day Surgery, Invasive Outpatients, and Emergency Department.
Sequences principal diagnosis and principal procedures according to documentation found in the medical records and UHDDS definitions.
Utilizes ongoing knowledge and reference material regarding DRGs to validate DRG assignments.
Accurately utilizes written federal and state regulations and written guideline regarding definitions and prioritizing of abstract data elements to assure uniformity of database.
Records abstracted include Inpatients, Same Day Surgery, Invasive Outpatients, and Emergency Department.
Verifies and/or abstracts required data into PC according to procedure.
Utilizes equipment and processes appropriately, to ensure efficient coding and abstracting; utilizes the established downtime procedures as needed.
Participates in maintaining DNFB and accounts receivable goal.
Maintains department level competencies. Participates in performance improvement activities (Q-edit, PA/HIM/REG shared folder monitoring, DRG Assurance Program committee participation).
Requirements
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: CCS, RHIA, or RHIT preferred.