Responsibilities
Coding and Documentation
Abstracts all emergency procedures using ICD-9-CM and CPT-4/HCPCS guidelines for code assignments.
Reviews medical record documentation to validate procedure charge indicated by nursing staff and accurately enters charges for procedures selected on chart ticket.
Accurately assigns appropriate procedure codes to emergency room patient records using ICD-9-CM system and CPT-4/HCPCS coding guidelines.
Uses the 3M system to abstract data elements related to procedures performed in the emergency department and determines appropriate sequencing of procedures.
Appends appropriate modifiers to CPT/HCPCS codes as required.
Posts charges for drug administration services (injections and infusions) in compliance with regulatory drug administration guidelines.
Assists the Business Office and external agencies in clarifying coding for reimbursement issues; handles all requests in a timely fashion.
Quality Assurance
Uses the nurses’ (Lynx) charge ticket to accurately and efficiently enter charges for evaluation and management (E&M) facility visits.
Consistently places records on pending diagnosis code status to prevent premature bill drop.
Maintains an accuracy rate not less than 93% based on internal and external reviews; engages in problem identification and resolution; assists in data gathering and chart auditing as necessary.
Participates in educational programs, in-services and training sessions; shares expertise with new personnel, volunteers and intern students where appropriate.
Collaboration and Partnership
Communicates with appropriate ER staff members when records with missing information are identified.
Demonstrates competencies in service to patients/customers of all ages by obtaining information about customer needs; speaks in a positive, professional manner about co‑workers, physicians and the facility.
Collaborates with Emergency Room nursing personnel and physicians; provides education and initiates process improvement opportunities to eliminate discrepancies between charge ticket and medical record documentation.
Consults with HIM Coding Supervisor, HIM Director, and Revenue Management Department staff regarding coding and charge master issues.
Other Duties as Assigned
Performs other duties as requested or assigned.
Qualifications
Experience - RHIT/RHIA plus 2 years acute care coding experience, or 4 years acute care coding experience; RHIT/RHIA with ICD-10 curriculum substitutes for all experience; CCS substitutes for 1 year acute care coding; Associates or Bachelor’s degree in Allied Health or Health Information Systems can substitute for minimum years of experience.
Education - High School diploma or equivalent.
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