Assigns ICD-10 CM and CPT codes to outpatient encounters, abstracts patient information into the coding/abstracting system. Participates in clinical documentation improvement initiatives.
ESSENTIAL FUNCTIONS AND JOB RESPONSIBILITIES:
Reviews patient’s entire medical record and assigns appropriate ICD-10 CM and CPT diagnosis and procedure codes and sequencing for outpatient encounters within 4 days of discharge.
Queries physicians when documentation is unclear or not recorded in the patient’s record.
Verifies accuracy of interfaced abstracted information. Abstracts designated clinical and demographic information into the medical record abstracting system.
Maintains accuracy rate of 98% on all coded data.
Reviews clinical documentation for improvement opportunities.
Participates in CHCA Coding Roundtable.
Participates in educational programs and inservice meetings; attends other meetings as required.
QUALIFICATIONS - LICENSES and CERTIFICATIONS:
High school diploma or equivalent. Successful completion of certified coding program. Associate or bachelor degree in health information management or related field preferred.
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Health Information Management Technician (RHIT), or Registered Health Information Administrator (RHIA).
Two years coding experience in an acute care setting and successful completion of a certified coding program.
Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.
I’ve had opportunities to improve my skills and move up in my career. Another way they are helping me to grow is by supporting me through graduate school, supporting my schedule and paying for a portion of my tuition.
Neonatal Intensive Care Unit