Position Summary: The incumbent of this position is responsible for identifying principal and secondary diagnoses and procedures on all inpatient discharges, assigning appropriate ICD-9-CM codes to each, and for verifying and maintaining the accuracy of the abstracted clinical and financial data. This position is also responsible for assuring compliance with all State and Federal regulations regarding correct coding initiatives and abstracting in an acute care Hospital environment. The incumbent will work in conjunction with case management, reimbursement and contracting staff to address documentation issues and/or areas of opportunity. Stays current in all changes impacting the abstracting and coding of inpatient Medical Records. The incumbent will be expected to stay current in all technological requirements and advancements necessary to carry out these duties as we migrate to an electronic health record (EHR). Maintains confidentiality of all patient and employee related information Position Responsibilities:
Utilizes appropriate systems, software and chart reviews to perform inpatient coding. Reviews patient s medical records and identifies principal and secondary diagnoses and principal and secondary procedures. Assigns appropriate codes using the International Classification of Disease Coding (ICD- 9 - CM) and CPT coding systems.
Works in conjunction with outside reviewers and Supervisor to facilitate coding compliance reviews.
Maintains expertise in and performs abstracting and coding functions, as required, to ensure smooth workflow. Responsible for the development and submission of accurate data submitted to other organizations or utilized for internal hospital reviews.
Works in conjunction with Case Management, Reimbursement, and Contracting staff to address documentation opportunities, correct coding initiatives, payment error prevention and reimbursement issues that are identified through the auditing / review process. Actively participates in Solutions to Excellence Program.
Assists in monthly closing activities.
Assists in training new coding personnel or students in coding procedures. Communicates and educates physicians to assure accurate code and DRG assignment.
Maintains expertise in all coding software and Hospital information systems as it relates to coding and abstracting of data. Enhances professional growth and development through participation in educational programs, current literature, inservice meetings, and workshops.
Maintains confidentiality. Annually completes all hospital mandatory education programs. Displays a positive, interested and motivated attitude with members of the hospital and medical staff and when representing the hospital to outside contacts and/or review agencies. Identifies customers and meets their needs and expectations.
Maintains established departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards.
Performs other assigned tasks to assist and support management, co-workers, hospital staff and others, as appropriate.
Displays and upholds CHH core values of dignity, compassion, service excellence, community and integrity. Consistently demonstrates caring for patients, for one another, and for the organization they are part of, and contributes to building trust, pride and camaraderie.
Qualifications Education: CPC, CCS, or RHIT required. Experience:
Understanding of Process Improvement techniques and tools.
Experience with hospital billing, charging and coding.
Knowledge of 3M, Meditech and coding compliance software applications.
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