Under the direct supervision of the Director, Operations and within established hospital and departmental policies and procedures, the incumbent performs the following functions : Reviews the medical records of inpatient, ambulatory, and emergency department patients to determine the diagnoses that identify the condition(s) for the patient's admission.
Lists diseases / conditions documented within the current admission. Identifies procedures performed for definitive treatment.
Assigns the code for diagnosis and procedure from ICD-9-CM or CPT-4. Ensures compliance with Uniform Hospital Discharge Data Sets (UHDDS), coding conventions and guidelines to maintain the integrity of indices, logs and registries generated.
On Emergency Department and ambulatory patients, verifies charge master generated CPT code. Seeks clarification from the attending physician in cases where documentation is absent, ambiguous or contradictory.
Ensure tests ordered and performed are covered according to Medicare Limitations of Coverage / Medical Necessity manual, and to ensure the appropriate APC / DRG is assigned.
Educates the physician regarding DRG and APC assignment and / or documentation requirements. Adheres to outside regulations and requirements, state reporting mandates and provides coding to minimize the number of days in receivable.
Communicates with Finance Dept. and clinical departments to resolve charge / coding issues as needed. Validates infusion center charges and corrects as necessary.
Provides feedback to Infusion staff on charging errors. Responds to requests for DRG changes and data entry corrections of specific data required by state, federal or departmental mandates.
Mentors and assists in the training of new Coders in the section. Works with the Medical Staff to ensure the accuracy of documentation and code assignment.
Maintains reference material on coding problems, updates or clarifications. Prepares daily assignments of records from previous day's discharges.
Answers telephone. Takes messages and distributes to appropriate person. Adhere to standards of coding / abstracting accuracy and timeliness.
Ensures confidentiality of patient medical records and hospital matters. Performs or monitors Quality Management audits and special projects.
Performs coding and data entry of outpatient diagnostic and clinic records. QUALIFICATIONS : Education :