STATEMENT OF PURPOSE: To ensure correctness of data submitted for reimbursement by reviewing encounter data for accuracy and completeness and assigning numeric codes for each diagnosis and procedure.
ESSENTIAL FUNCTIONS: - Receives completed daily folders from each facility/department and analyzes each for completeness, accuracy of input and compliance with SLFHC policy and rate schedule
- Reviews patient records and assigns numeric codes for each diagnosis and procedure
- Reads and analyzes medical records to help identify all diagnoses and procedures relevant to the current episode of patient care
- Researches encounter integrity for ICD-9, ICD-10 and CPT links and corrects if necessary
- Confirms encounter information and obtains missing information by reviewing the patients medical records chart
- Clarifies inconsistent, ambiguous or non-specific information in a medical record by consulting with the supervisor or the responsible medical practitioner
- Confirms codes to patients current episode of care
- Notifies Lead Certified Medical Coder when training issues are discovered
- Formulates training sessions or literature pertaining to coding and input issues
EDUCATION AND EXPERIENCE: - High School diploma or equivalency
- College courses in Biology, Medical Terminology, Coding
- Certified Coder
- Three years experience in a medical office environment
- Computer literate