Job Description
Job Description Performs designated abstracting and coding functions as specified. Assigns diagnostic and procedure codes to inpatient records. Completes data abstract in 3M for each record coded. Ensures records are accurately and completely coded according to hospital approved standards. Reports to the Coding Supervisor of Health Information Management (HIM).
Responsibilities Reviews patient's entire current medical record and assigns appropriate code. Determines the sequence of diagnoses according to uniform hospital discharge data. Reviews all surgical and designated diagnostic procedures and assigns appropriate procedure codes. Requests diagnoses from physicians when not recorded on discharge, if information is incomplete, or if information is ambiguous. Abstracts required data items into the medical record abstract system, and ensures data coming from the AS400 is accurate. Ensures the coding is compliant with CMS, AHA, AMA, DHHS and other governing agency requirements. Assigns present on admission (POA) value for inpatient diagnosis. Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge. Enhances professional growth and development through participation in educational programs, in-services, and workshops and by reading current literature. Participates in educational programs relating to job and overall competencies. Attends meetings as required and participates on committees as directed. Maintains established departmental policies and procedures, objectives, quality assurance, safety, environmental and infection control standards. Ensures compliance with hospital policies, procedures, management systems and documentation. Assists in training and orientation of new personnel in coding procedures. Assists in the care and maintenance of department equipment and supplies. Maintains a positive environment for the public, patients, hospital personnel, and medical staff by providing an E3 experience. Provides relief when necessary to ensure adequate coverage at all times. Performs other duties assigned or requested by the Coding Supervisor or HIM Director.
Qualifications Experience - One or more years of coding experience in a health related setting. Should be able to concentrate during numerous interruptions Must be able to withstand pressure of scrutiny of work. Must demonstrate knowledge of ICD-9-CM coding system, 3M abstractor/encoder/grouper, MSDRG reimbursement system. Must possess good verbal and written communication skills and be proficient in English and spelling. Must have good computer skills. Must be able to work with minimum supervision. Must be able to type and sit for long periods of time. Must maintain professional credentials.
Education High School Diploma or GED. Registration as Health Information Administrator (RHIA) or Health Information Technician (RHIT) or certification by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a: Certified Coding Specialist (CCS), Certified Professional Coder (CPC) or Professional Coder - Hospital (CCP-H). Must have excellent verbal and written communication skills. Other office skills include daily usage of computers, fax and photocopiers and telephones. Franciscan Missionaries of Our Lady Health System
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