Job Description

• Assign the principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the medical record utilizing knowledge of anatomy, physiology, medical terminology, and pathology. Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign diagnosis and / or procedure. Determine diagnoses that were treated, monitored, and evaluated and procedures done during the episode of care and assign appropriate codes. Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations.
• Ensure the diagnoses and procedures are sequenced in order of their clinical significance to accurately assign the appropriate DRG, APC or payment tier under the Prospective Payment system to guarantee accurate reimbursement. Review coding for accuracy and completeness prior to submission to billing.
• Abstract required medical and demographic information from the medical record and enter the data into the system to ensure accuracy of the database. Responsible for correcting any data found to be in error after reviewing the medical record and comparing with system entries.
• Ensures all required component parts of the medical record that pertain to coding are present, accurate and comply with CMS, JCAHO, and client requirements. Identify incomplete or conflicting documentation in the medical record and formulate a physician query to obtain missing documentation and/ or clarification to accurately complete the coding process. Utilize computer applications and resources essential to completing the coding process efficiently.
• Meets coding quality and quantity expectations.

Position Requirements:

• Minimum 2 years of Medical Coding experience required
• Experience with Professional Fee Coding
• Experience with EHR systems
• Education, Experience & Certification Requirements vary based on coding assigned. Accepted certifications from American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) include:
• Registered Health Information Management Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Certified Coding Associate (CCA) · Certified Coding Specialist (CCS)
• Certified Coding Specialist- Physician-Based (CCS-P)
• Certified Professional Coder (CPC)

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