Position Summary

Evaluates medical records, provides clinical and surgical abstraction and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines.

Core Functions

1. Analyzes medical information from medical records. Accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements. Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes. Provides thorough, timely and accurate coding in accordance to department specific productivity and quality standards. Codes ICD CM and CPT4 for accurate APC assignment. Addresses National Correct Coding Initiative (NCCI) edits as appropriate. Reconciliation of charges as required.
2. Abstracts clinical diagnoses, procedure codes and documents other pertinent information obtained from the medical record into the electronic medical records. Seeks out missing information and creates complete records, including items such as disease and procedure codes, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysts, supervisor or individual department for clarification/additional information for accurate code assignment.
3. Provides quality assurance for medical records. For all assigned records and/or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards.
4. As assigned, compiles daily and monthly reports; tabulates data from medical records for research or analysis purposes.
5. Works independently under regular supervision. Uses specialized knowledge for accurate assignment of ICD/CPT codes according to national guidelines. May seek guidance for correct interpretation of coding guidelines and LCDs (Local Coverage Determinations).

Minimum Qualifications

High school diploma/GED or equivalent working knowledge and specialized formal training equivalent to the two year certification course in medical record keeping principles and practices, anatomy, physiology, pathology, medical terminology, standard nomenclature, and classification of diagnoses and operations, or an Associate’s degree in a related health care field.

Requires at least one of the following: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician (CCS-P), Certified Coding Associate (CCA), Certified Professional Coder – Apprentice (CPC-A), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), in an active status with the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC). Certification may also include a general area of specialty.

Six months providing professional coding services or other related healthcare experience within a broad range of health care facilities.

Must demonstrate a level of knowledge and understanding of ICD and CPT coding principles as recommended by the American Health Information Management Association coding competencies, and as normally demonstrated by certification by the American Academy of Professional Coders.

Must be able to work effectively and efficiently in a remote setting, utilizing common office programs, coding software and abstracting systems.

Preferred Qualifications

Specialty Certification.

Additional related education and/or experience preferred.

EEO Statement

EEO/Disabled/Veterans

Our organization supports a drug-free work environment.

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