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.
Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures. Assigns proper ICD‑10 CM and HCPCS diagnostic and operative procedure codes to charts and related records by reference to designated coding manuals and other reference material.
Applies uniform hospital discharge data-set definitions to select the principal diagnosis, principal procedure, and other diagnoses and procedures that require coding, as well as other data items required to maintain the hospital database.
Applies sequencing guidelines to coded data according to official coding rules.
Assigns DRG code to each record according to healthcare finance-administration directives. Enters coded/abstracted information into DRG grouper, analyzes groupings, and observes for assigned appropriate DRG weight for reimbursement.
Assesses the adequacy of medical record documentation to ensure that it supports the principal diagnosis, principal procedure, complications, and comorbid conditions assigned codes. Consults with the appropriate physician to clarify medical record information.
Answers physicians/clinicians questions regarding coding principles, DRG assignment, and prospective payment system. Assists finance, data processing, and other departments with coding/DRG issues.
Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature, and so forth. Progresses in the learning of ICD-10-CM and PC coding principals and assignment.
Retrieves emergency, urgent care, and ambulatory care records and alphabetizes and attaches corresponding laboratory reports to ensure accurate assignment of ICD-9 and CPT-4 codes.
Attends all required safety training programs and can describe his or her responsibilities related to general safety, department/service safety, and specific job‑related hazards.
Follows the hospital exposure control plans/bloodborne and airborne pathogens.
Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
Promotes effective working relations and works effectively as part of a department/unit team inter- and intradepartmentally to facilitate the department’s/unit’s ability to meet its goals and objectives.
Equivalent to an associate’s degree in medical information technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD 10‑CM coding and prospective payment) preferred. More extensive clinical background preferred for physician CDI and physician interaction.
Bachelor degree preferred.
Five years acute care experienced required.
Designation as a CCS required.
Certified Coding Specialist required.