This position reports to the Director of HIM. Responsible for ensuring that inpatient, emergency department, ambulatory surgery and ancillary encounters are coded and abstracted under the ICD-10-CM & PC and HCPCS (CPT) System for statistical and DRG assignment purposes.
Under general supervision and according to established procedures, assigns diagnostic codes to medical record information. Abstracts required data into hospital abstracting system. The outcome of information gathered is used to determine the hospital database and reimbursement of hospital claims. Certain Clinical Documentation Improvement functions are expected in this position pertaining to inpatient Medicare and senior Medicare patients with MediCal APR-DRG assignment. Extensive interaction with physicians and responsible for physician education pertaining to principal diagnostic assignments, ICD-10-CM and PC physician education. Smart review of Medicare patients is required.
This position works closely with the CBO and CFO relative to DNFB, coding or abstracting errors. The Coder is also responsible for daily reporting of HIM Units of Service and monthly DNFB reports.