Description:
Performs the coding of outpatient and/or inpatient and ancillary medical records as well as various Health Information Management duties.
Functions of the Position (not an exhaustive list):
- Review medical records classified as inpatient, observation, treatment room, Emergency Department and ancillary
- Assign appropriate diagnosis/procedure codes using the ICD-10 and CPT-4 classification systems. Assign codes using coding books or by using the 3M/code finder computer system
- Follow established coding guidelines when assigning diagnosis/procedure codes to records
- Request diagnosis/procedural information from physician when information is not available at the time of coding
- Utilize approved resources for coding purposes, i.e. CMS.gov website
Requirements:
Education:
- High School diploma or equivalent
- Knowledge of Medical Terminology, Anatomy and Physiology, CPT and/or ICD-10 PCS, and ICD10-CM coding systems
- RHIT, RHIA, or professional coding credential required
Experience
- Two years coding experience preferred