Job Description

Under the general direction of the Coding Manager, this position reviews the medical record to verify diagnosis and procedures and Present on Admission Indicators.  The Coder abstracts the information by using the appropriate coding classification system.  Verifies codes for statistical and reimbursement purposes.   PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:

• Performs a complete chart review.  Assigns ICD-10-CM, ICD-10 PCS and/or CPT codes in accordance with coding and reimbursement guidelines.
• Assists in obtaining final diagnosis and contacting physicians for clarification of documentation when needed.
• Verifies and abstracts specific clinical and demographic data:
  • Discharge disposition
  • Transfer destination
  • Date and responsible party for all procedures.
• Verifies the DRG assignment, paying special attention to DRG’s in which a comorbid condition or complication has been identified.
• Inputs the appropriate information into the hospital system discharge abstract.
• Refers appropriate charts for DRG Validation, prints the coding sheets and attaches it to the record for review based on Departmental Policy.
• Performs related duties such as answering and routing telephone calls and receiving people requesting information and services in the department.
• Participation in continuing education programs as requested by Management
• Participate in department staff training programs to develop skills that will achieve business goals and foster individual career growth.
• Assists in the implementation of the ICD-10 Coding Classification system.
• Trains clinic staff on the use of ICD-10 codes.
• Reconciles daily Inpatient reports and provides weekly feedback to Department Management 
• Performs or assists with other duties assigned by the Coding Manager.
• Assists in training of new personnel.
• Performs other similar and related duties as required or directed.

Qualifications

JOB KNOWLEDGE AND SKILLS:

• Working knowledge of ICD-9-CM and CPT coding system, DRG, APG, payment systems, medical terminology, anatomy and physiology.
• Excellent organizational and communication skills.
• Working knowledge of computers preferred

  EDUCATION:

• Completion of coding certificate program required.

EXPERIENCE:

• An equivalent combination of education and experience, which provides proficiency in the areas of responsibility listed above, may be substituted for the above education and experience requirements.

LICENSES, ETC.:

• RHIT/RHIA or CCS Required

WORKING CONDITIONS/PHYSICAL DEMANDS:

• General office environment.
• Frequent use of a computer terminal.
• Frequent contact with physicians, nursing, administration, finance, and outside audit personnel.

Additional Information

All your information will be kept confidential according to EEO guidelines.

AMERICANS WITH DISABILITIES STATEMENT:

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Tufts Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.

COVID-19 POLICY:

Please note that effective October 1, 2021, as a condition of employment at Tufts Medical Center, all employees and new hires must have received their complete dose of the COVID-19 vaccine, unless they have been granted an exemption.