Abstracts clinical information from medical records. Primarily assigns appropriate ICD-10-CM codes on inpatient accounts but when necessary, will assign appropriate ICD-10-CM codes and CPT-4 procedure codes to outpatient accounts.
A. Assigns ICD-10-CM and CPT-4 codes in accordance with coding and reimbursement guidelines including, but not limited to, the following: 1.Identifies principal and secondary diagnoses and procedures based upon UHDDS standards. 2.Uses fifth digit and sequencing conventions. 3.Documentation is present to substantiate codes assigned. B. Abstracts relevant clinical and demographic information from the medical record. C. Maintains a control system to assure completeness of the indexing system; enters all corrections in response to system edits and internal controls. Serves as a coding resource for Patient Financial Services. D. Refers coding and system questions to the Director/Supervisor in a timely manner for determination and guideline development. E. Assists in abstracting and retrieval of data for selected studies requested by Clinical Excellence. F. Keeps current on coding guidelines, rules and regulations, and new codes. G. Remote coding agreement signed and approved by Director. H. Other duties as assigned.
1.Working knowledge of the ICD-10-CM and CPT-4 coding systems, medical terminology, anatomy and physiology. 2. Experience in computer operations. 3. A minimum of two (2) years hospital coding experience or equivalent. 4. Types accurately at least 30 WPM. 5. Mandatory Continuing Education: Customer Service, Fire and Safety, Corporate Compliance (including Confidentiality), Infection Control, and education required by regulatory, accreditation bodies, scope of practice, and/or Hancock Regional Hospital. Must have Certified Professional Coder (CPC) Certified Coding Associate (CCA) Certified Clinical Coder (CCS) Registered Health Information Technician (RHIT) or Registered Health Information Administration (RHIA) credentials
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