Medical Records Coder (UT Health Physicians)

Job Summary:

Under direct supervision, responsible for conducting review of inpatient and outpatient coding, assuring coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes. Performs all tasks required to facilitate medical billing to include abstracting complex patient related data from medical records and coding of diagnoses and procedures using the ICD-10 and CPT classification systems.

Job Duties:

1. Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
   
2. Provides technical work in documentation and coding for medical billing, abstracts 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. Obtains medical records and charge fee information from patient care area.
   
5. Contacts other facilities to obtain medical records and information needed to bill for services rendered.
   
6. Verifies charge capture and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; ensures proper documentation guidelines are followed.
   
7. Codes diagnosis and procedures using classification coding systems.
   
8. Reviews charge documents for completeness.
   
9. Performs all other duties as assigned.
   
    

Education:

High school diploma or GED is required.

Experience:

None to five (5) years of experience in medical record abstraction and coding is preferred. 

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.

Supervisory Requirements:

• None