Responsibilities

• Reviews medical records to apply codes for diagnoses and operative and diagnostic procedures according to the current edition of the International Classification of Diseases and Operations and in the HCPCS CPT-4 coding system in order to ensure information for billing and data collection purposes is accurate, utilizing the hospital's coding software.
• Maintains an average productivity rate of 2 inpatient charts per hour and 7 outpatient charts per hour.
• Provides Coding Manager with productivity statistics and quality results on a biweekly basis.
• Abstracts relevant information from each medical record using UHDDS definitions for input into MEDITECH EMR to provide data for the processing of reports.
• Reviews incomplete record files for the completion of diagnostic information by the physician and the application of codes by the coding technician.
• Participates in second-level chart reviews, auditing peer-coded medical records to ensure completeness, quality and accuracy of coded medical records.
• Works closely with Clinical Documentation Improvement Specialists to retrieve pertinent documentation from clinicians to ensure quality, consistency and integrity of medical record documentation.
• Possesses a good level of understanding of the DRG validation procedure and DRG information for inpatient coding, as well as a good understanding of CPT guidelines for outpatient coding, ensuring that the accuracy rate of 95% is maintained.
• Performs DRG validations on all appropriate charts to ensure that these charts will meet all requirements of outside review and regulatory agency requirements.
• Able to work at the hospital or remotely and maintain accountability and consistency of assigned work.
• Alerts Coding Manager of any charts that may be a potential liability to the hospital.
• Participates in all performance improvement functions and department meetings assigned by the Coding Manger and HIM Director.
• Participates in continuing education programs specific to coding and abstracting functions, as assigned by the Coding Manager.
• Participates in continuing education programs specific to coding and abstracting functions, as assigned by the Coding Manager.