Under general supervision, responsible for conducting the quality review of inpatient and outpatient coding, assures coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes.
1. Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
2. Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
3. Works coding related charge review and claim edits daily to ensure timely and accurate billing.
4. Researches and resolves coding related issues and assists in meeting productivity and quality reviews. Monitors and reports coding opportunities and escalates as needed.
5. Verifies charge entry and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
6. Review medical records and charge fee information from patient care area.
7. Contacts other facilities to obtain medical records and information needed to bill for services rendered.
8. Reviews EPIC queues and correct coding edits.
9. Codes diagnosis and procedures using classification coding systems.
10. Reviews charge documents for completeness.
11. Performs all other duties as assigned.
High school diploma or GED is required.
Associate degree in Coding is preferred.
Three (3) years’ experience in medical record abstraction and coding is required.
Additional Licenses and Certifications:
Accreditation from a professional coding organization, such as American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) certification is required.