EMAIL: respree@ughospital.com
POSITION SUMMARY (Summarize the basic function of the position)
Essential duties and responsibilities of the Health Information Coder include knowledge of ICD-9-CM and CPT coding techniques, concurrent review, medical terminology and abbreviations, medical record content, and legal aspects of patient medical records. Report directly to the Health Information Management Director
DUTIES AND RESPONSIBILITIES Indicate job responsibilities to be performed to accomplish the job functions)
1. Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex IP and OP encounters.
2. Review provided documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures.
3. Utilize technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-9-CM diagnoses and procedures.
4. Ensure accurate coding by clarifying diagnosis and procedural information through a query process.
5. Assign present on admission (POA) value for impatient and OP diagnoses.
6. Extract required information from source documentation and enter into encoder and abstracting system.
7. Identifies non-payment conditions (HAC) and when required, report through established procedures.
8. Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge.
9. Prioritize work to ensure timeframe of medical record coding meets regulatory requirements.
10. Serve as a resource for coding related questions to other employees and medical staff as appropriate.
11. Meet performance and quality standards.
12. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
13. Keeps abreast of coding guidelines and reimbursement reporting requirements, and advise management team of my concerns once identified for resolution.
14. Performs other related duties as requested.
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Certified InPatient coder needed