The Coder is responsible for timely review of patient records in order to identify an appropriate selection of codes which will accurately reflect the reason for admission, extent of care received, and level of severity of illness. Coder is further responsible for insuring that all data elements required for federal and state reporting are collected and included in the patient's demographic record. Abstracts records into Hospital's computer system. This job description in no way states or implies that these are the only duties to be performed by this employee. He or she will be required to follow any other instructions and to perform any other duties requested by his or her supervisor.
1. Assigns appropriate ICD-10-CM, ICD-10-PCS and CPT codes to medical records. Reviews entire record for all diagnosis and surgical procedures. Contacts physician when additional information is needed to accurately code the encounter. Assigns appropriate ICD-10-CM, ICD-10-PCS and CPT codes two days post visit. Sequences diagnosis and procedures at least 98% of the time. Assigns appropriate charge codes to Emergency Department encounters at least 98% of the time.
2. Abstracts medical records into the computer system. Ensures records are abstracted with all appropriate data at least 97% of the time. Writes completed record to appropriate queue at least 99% of the time, or reassigns to the appropriate work queue.
3. Calls appropriate department to obtain missing documentation, within two weeks of encounter.
4. Adheres to safety practices, reports accidents/hazards and maintains equipment as outlined in hospital policies.
About Our Benefits:
Amazing people deserve amazing benefits. We strive to employ and retain the most highly qualified individuals by providing equitable wages and benefits, promoting from within, and supporting the continuing education efforts of our staff. You will be valued and rewarded for the work you do here with excellent pay and outstanding benefits. At MCH, you'll find great opportunities for career advancement as well as personal and professional growth.
Full-time employees enjoy:
High School or better.
Registered Health Information Technologist or Certified Coding Specialist. Knowledge of coding, medical terminology, Anatomy and Physiology, and computerized medical records/abstracting systems. One year of ICD-9-CM and CPT-4 (HCPCS) coding and charge experience. ICD-10-CM, ICD-10-PCS training.