Reviews and interprets documentation in the Emergency Department Medical Record to identify diagnosis and procedures for coding/abstracting and charging. Accurately assigns ICD-9 CM codes as appropriate. Assigns appropriate procedural/supply charges according to approved APC charge master and charge sheet. Enters assigned coding/charge information accurately into the Meditech system. Assesses the adequacy of health record documentation to ensure that the medical record supports all diagnosis, procedures and charges and clarifies non-specific or conflicting information on the medical record with the appropriate staff member. Applies knowledge of anatomy and physiology, disease processes, pharmacology, ED processes and American Hospital Association coding guidelines. Correctly abstracts medical records for SPARCS database. Recommends addendums to APC charge master to increase billable revenue for the ED. Contributes to the currency of coding policies. Collaborates with Billing/ Materials Management/ED Unit/Supply Clerk to maintain accuracy of the ED supply sheets, updating as needed. Ensures all charges generated within 72 hours of ED visit. Assists with data collection as needed to support current PI initiatives. Investigates billing complaints/discrepancies, following up as appropriate.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED