Hudson Regional Hospital
Secaucus, NJ, USA
Job Description Job Description Job Duties: Reviews Inpatient medical record documentation to determine accurate code assignments. principal diagnosis, identify and assign co-morbidities and complications, secondary diagnoses, present on admission indicator, discharge disposition, Hospital Acquired conditions, principal procedure and secondary procedures on all discharged inpatient records to arrive at the most appropriate DRG assignment. Accurately abstracts ICD-10 diagnosis, procedure codes and CPT codes Performs clinical data abstracting from patient record in the encoder system. Knowledge of anatomy, physiology and medical terminology and able to apply Has coding compliance rate < 98.5% Immediately reports to DIR, HIS on issues with documentation; missing or requires clarification. Generates Coding Query notifications to Providers for where documentation requires clarification due to inconsistencies in Diagnosis and/or Surgical Procedures. Provider...