Job description
Responsible for the proper coding and abstracting of inpatient facility medical records using ICD-10-CM diagnosis and PCS codes in accordance with ICD 10 coding conventions and Coding guidelines.
Knowledge and adherence to the Official Coding Guidelines for ICD 10 CM and PCS is required. Participation in on-going coding training and education is essential and required for this position. Maintaining annual coding certification through the American Health Information Management Association (AHIMA) or the AAPC is also required.
Required:
Coding Credential through the AAPC and/or AHIMA (CPC/ CPC-A/CCS/RHIT/RHIA/CCA) required.
Outpatient Coder with at least 2 years' experience preferred.
Knowledge and adherence to the Official Coding Guidelines for ICD 10 CM and PCS is required. Participation in on-going coding training and education is essential and required for this position. Maintaining annual coding certification through the American Health Information Management Association (AHIMA) or the AAPC is also required.
II. Essential Functions -
- Ability to read and comprehend the medical record to identify all diagnoses, operations, and procedures relevant to the patient admission.
- Translate diagnostic and procedural documentation into the appropriate ICD-10-CM, PCS, SOI, and ROM assignments.
- Select the appropriate principal diagnosis code, secondary diagnoses, and procedure codes according to the UHDDS.
- Analyze the circumstances of admission to ensure proper sequencing, selection of discharge disposition, and Present on Admission (POA) assignment.
- Appropriate capture Complications and Comorbidities
- Ensure appropriate DRG assignment.
- Identify cases that require further clarification based on the clinical indicators in the record.
- Communicate and work with the Clinical Documentation Specialist
- Review medical record information using Epic.
- Abstract records in an accurate manner according to established procedures and guidelines.
- Meet and/or exceed coding quality and productivity standards.
- Review and address coding validation edits, 3M edits, and participate in Coding Prebill reviews as well as peer reviews.
- Demonstrate and incorporate a working knowledge of the Epic system for retrieval of clinical data for coding purposes.
- Assist with coding shadowing and cross training as needed.
Required:
- High School Diploma required
- Two year degree preferred
Coding Credential through the AAPC and/or AHIMA (CPC/ CPC-A/CCS/RHIT/RHIA/CCA) required.
Outpatient Coder with at least 2 years' experience preferred.
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