Job Summary Accountable for the conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in the sequencing of diagnoses/procedures in accordance with coding guidelines. Ensures that records are coded in an accurate and timely manner. Duties and Responsibilities Demonstrates Competency in the Following Areas: Ensures that records are coded within three days of discharge, excluding weekends and holidays. Reviews the chart thoroughly to ascertain all diagnoses/procedures. Contact the responsible physician in a professional, tactful manner if the diagnosis is not available on the chart. Refers chart to the director if there is a question regarding the diagnoses/codes. Utilizes computerized coding/abstracting equipment. Codes all diagnoses/procedures in accordance with ICD-10-CM coding principles and the Coding Manual. Meets productivity standard of assigning codes based on account type. Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded. Maintains 99% rate of information correctly abstracted. Assists with education and coding for medical necessity. Maintains the number of DRG/coding changes below the 3% quarterly per PRO threshold. Reviews coding periodicals within seven (7) days of receipt. Notifies the director whenever work is more than 48 hours behind the work deadline. Ensures data quality and optimum reimbursement allowable under the federal and state payment systems. Acts as a resource person to hospital and clinic staff for coding and may provide education regarding coding changes/issues. Maintains a good working relationship within the department, other departments, and medical staff. Must be familiar with the following manuals: Administration, Health Information Management Department, Fire Safety, Emergency Management and Safety, HIPAA. Willing to accept additional assignments. Performs performance improvement functions through data collection and documentation review.
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Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree