Summary of Essential Functions
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Processes, reviews, abstracts, codes and indexes diseases, operations, treatments and computes observation time charges on outpatient medical records, ensuring governmental compliance on regulatory issues
Educational Requirements
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High School Diploma or equivalent.
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Must be able to communicate effectively in English, both verbally and in writing.
Knowledge/Skills/Abilities
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Minimum of one year experience outpatient coding in an acute health care setting.
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CCS preferred.
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Ability to interpret medical record, concentrate and maintain accuracy in spite of interruptions, initiative, to use standard office equipment and to maintain confidentiality with regard to aspects of work.
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Knowledge of medical terminology, anatomy, coding/classification systems, reimbursement principles, and coding software preferred.
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Organizational skills and good communication skills to assist physicians in questions regarding documentation of diagnostic entries, according to Joint Comission/HCFA and hospital guidelines.
Physical Requirements
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Vision acuity, hearing sensitivity and manual dexterity.
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Occasional bending, stooping, kneeling, reaching, lifting and standing.
Duties and Responsibilities
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Reviews and codes all diagnoses according to ICD-9-CM coding classification systems and regulatory guidelines. Maintaining a 95% or higher quality rating.
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Reviews and codes all procedures according to ICD-9-CM coding classification systems and regulatory guidelines. Maintaining a 95% or higher quality rating.
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Reviews and codes all procedures according to CPT-4 coding classification systems and regulatory guidelines. Maintaining a 95% or higher quality rating.
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Demonstrates a consistent level of performance; strives to maintain a minimum productivity of 15 charts per hour.
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Abstracts and indexes medical records, according to governmental compliance and hospital guidelines.
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Verifies and processes Medicare 72 hour messages to ensure proper account handling.
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Supports and participates in meeting departmental goals.
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Displays professionalism and courtesy in assisting physicians and other departments in problem solving.
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Reviews outpatient records, computes observation time and posts the charges to the patient account.
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Performs all other tasks/responsibilities as necessary.