Apply the appropriate diagnostic and procedural code to patient health records for purposes of document retrieval, analysis and claim processing. Abstract pertinent information from patient records. Assign the International Classification of Diseases, Clinical Modification (ICD), Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, creating Ambulatory Patient Classification (APC) or Diagnosis-Related Group (DRG) assignments. Perform complex coding. Obtain acceptable productivity/quality rates as defined per coding policy. Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. Maintain knowledge of, comply with and keep abreast of coding guidelines and reimbursement reporting requirements. Conduct chart audits for physician documentation requirements & internal coding; provide associate/physician & education as appropriate. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding guidelines.
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Job Type
Full-time
Career Level
Entry Level
Industry
Religious, Grantmaking, Civic, Professional, and Similar Organizations
Education Level
High school or GED
Number of Employees
5,001-10,000 employees