Atrium Health
Charlotte, NC, USA
Job Description Job Summary Reviews clinical documentation and diagnostic results as appropriate to abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS1 and CPT 4 codes for reimbursement, external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and other regulatory edits. Code and abstract medical records of moderate to high complexity within the Primary Enterprise acute care facilities. Essential Functions Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines. Reviews charges and Evaluation and Management levels. Demonstrates...