JOB SUMMARY: • Ensures accurate coding of diagnosis and procedures of all patients medical records for reimbursement and statistical reporting. • Observes routine work schedules while following hospital and departmental policies and procedures. • Exercises independent judgment and decision making. Plans own work and applies medical knowledge to complete tasks. • Demonstrates knowledge and skills necessary to carry out his/her role in the management of information. • Employee’s role includes that of a generator, collector, analyzer, user and/or enterer of data and/or information. • Limited protected health information access
JOB SPECIFIC DUTIES: • Creates daily worklist from Compiled Reports in Meditech. Assesses IP, OP, ER, RCR, CLI and work according to priority. • Reviews older worklist for completion. Send emails to necessary personnel for incomplete charts. • Reviews entire medical record (per EMR/ scanned documents) to include discharge summary, H&P, operative reports, pathology reports, ancillary reports as well as necessary nursing documentation to substantiate principal diagnosis. o Uses independent judgement to determine sequencing. • Reviews chart for any complications or co-morbid conditions and other determining factors to verify the DRG/ APC assigned by the encoder. • Consults with physician or CDI Specialist as needed for diagnosis/ procedure completion or clarification. Initiates query sheet according to procedure. • Reviews diagnoses on records ensuring they meet the guidelines set forth by Medicare National Coverage Determination (NCDs) and Local Medical Review Policies (LCDs) on selected tests. Follows procedures for tests that do not meet these guidelines. (Mod GZ) • Ensures all modifiers are appropriately added to HCPCS according to CMS/ CCI guidelines and rules. • Keeps current on all new updates (ICD-10/ CPT/HCPCS/ modifiers). Research as needed. • Demonstrates knowledge of Craneware as main research/ search tool. • Demonstrates knowledge of DRG and APC classification system and its impact on reimbursement and keeps abreast of the latest revisions to Federal Regulations. Understands disease process and fundamentals of medicine and pharmacology. • Has a thorough knowledge of 3M Encoder system and its functionality and interface w/ the charges. • Abstracts charts coded according to procedure as well as any data needed for projects indicated. (Expired pts) • Demonstrates knowledge of all abstract screens, fields and pop-up edits to ensure abstract is finalized. • Completes “Reminders” edits in BAR Collector Desktop daily to avoid holding up the billing process.
Required Skills
LICENSE/CERTIFICATION: RHIT, RHIA, CCS, or CPC or eligible to obtain within a year.
EDUCATION: Must be a graduate of an accredited Health Information Management Technology program or Health Information Management Administration program.
EXPERIENCE: 3-5 years HIM and coding experience preferred. Previous experience in the Tumor Registry field would be beneficial.
Required Experience
1 - 2 years experience with hospital coding preferred. CCS, CPC, or RHIT preferred or eligible.
LICENSE/CERTIFICATION: RHIT, RHIA, CCS, or CPC or eligible to obtain within a year.
EDUCATION: Must be a graduate of an accredited Health Information Management Technology program or Health Information Management Administration program.
EXPERIENCE: 3-5 years HIM and coding experience preferred. Previous experience in the Tumor Registry field would be beneficial.