Job description
To assign and group diagnoses, procedure and level codes based on medical record documentation in accordance with coding compliance, regulatory and reimbursement requirements. To ensure appropriate coding for case mix classification and expected reimbursement based on assigned diagnosis, procedure and level codes and reimbursement classifications as supported by medical record documentation. To enter diagnoses, procedure and level codes and patient demographic information into computer system.
Description:
- Analyzes, sequences and validates assigned codes based on medical record documentation using the automated encoder, book and coding compliance resources.
- Demonstrates complete understanding of coding rules, anatomy, physiology and medical terminology to appropriately code patient information.
- Reviews all medical record documentation to determine and assign diagnoses, procedures, level codes and modifiers.
- Selects the appropriate reimbursement grouper based on financial class for the particular account.
- Ensures that coding compliance, regulatory and reimbursement requirements are met through the process of assigning reimbursement classifications.
- Abstracts and enters demographic, clinical and related patient information into the computer system.
- Assess adequacy of documentation and queries physicians and other healthcare providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding and grouping.
- Reconciles, identifies and retrieves medical records to be coded.
- Maintains a 95% ongoing accuracy rate.
- Consistently achieves daily coding output within the minimal productivity standards set by MACC. Self-manages and prioritizes work flow to achieve timely submission of claims and optimal productivity.
- Maintains accurate productivity logs and provides this information to management in a timely fashion.
- Assists in the orientation and development of new coding personnel.
- Assumes professional responsibility for development of skills and ongoing education to maintain certification.
- Remains abreast of developments in health information management by pursuing a program of professional development, attending educational programs and meetings and reviewing pertinent literature.
- Continuously monitors medical record documentation, individual performance and department workflow as related to the coding function to identify problems and potential solutions (especially related to errors and compliance issues). Communicates with the Operations Manager to find solutions and implement changes to increase productivity and department efficiency.
- Performs all duties and interacts with others in a professional manner.
- Performs other related duties as assigned.
Qualifications:
- High School Diploma or GED.
- Two years of Outpatient Coding experience preferred.
- Must meet CPC Certification eligibility requirements and must obtain CPC Certification within 3 months of position.
- Ability to read, write and communicate in English
- Comprehensive understanding of ICD10 and CPT coding.
- Demonstrated ability to create strong working relations with physicians and practices.
- Capable of working independently as well as in a team environment.
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