Reports to the Manager of Coding & Records. Reviews, codes, and analyzes medical records to abstract relevant data into the online computer system. Assigns DRGs to Medicare, Medicaid, and other required payors and determines DRG and APC assignment on outpatient and inpatient records.
This is a remote position, but candidates must reside in one of the following states: Indiana, Michigan, Illinois, Kansas, Ohio, Georgia, Kentucky, Florida, Idaho, Minnesota, Tennessee, Wisconsin, Colorado, South Carolina, North Carolina, or Texas.
Responsibilities
- Review and analyze discharged patient medical records to ensure all applicable patient data is available for coding and abstracting.
- Check diagnoses and procedures to ensure accurate coding and sequencing according to established coding principles and guidelines.
- Follow AHA, AHIMA, and CMS coding guidelines for outpatient and inpatient records.
- Obtain accurate and complete patient data from discharge summaries, history and physicals, consults, progress notes, laboratory reports, radiology, operative, and pathology reports.
- Code inpatient procedures and outpatient surgical records according to ICD-9-CM, CPT-4, or physician E&M codes as applicable.
- Refer questionable diagnoses and sequencing issues to physicians for clarification.
- Communicate with Patient Accounts staff and coordinate questionable abstracting or coding problems with the department manager.
- Assign ICD-9-CM codes and complete coding summaries.
- Review error messages and incompatible DRGs for second-level review.
- Complete medical records for abstracting and resolve medical necessity issues.
- Abstract diagnosis and procedure codes into the hospital computer system.
- Designate APC assignment on outpatient medical records.
- Assign DRGs or APCs to Medicare, Medicaid, and other required payor records using computerized grouper software.
- Abstract professional E&M codes, professional procedure codes, and technical component procedures into the hospital charging module.
- Enter charges on ED and OBS charts when applicable.
- Maintain coding accuracy through internal and external audits, Coding Clinic review, and coding workshops.
- Meet productivity and accuracy standards for assigned record types.
- Perform other job-related duties and projects as assigned.
Requirements & Qualifications
Qualifications
- Certification as CCS is required.
- One of the following certifications is also acceptable or required depending on training and experience: RHIT, RHIA, CCS, CCS-P, CPC, or CPC-H.
- Knowledge and training in more than two work types.
- Three years of inpatient coding and/or CPT ambulatory surgery coding experience.
- Ability to mentor and train other coders.
- Three years of advanced medical and surgical coding experience in a large acute care facility is preferred.
- Knowledge of medical terminology, anatomy, and physiology.
- Strong understanding of DRG assignment and optimization.
- Knowledge of state and federal reimbursement guidelines.
- Ability to compile and process patient information from medical records.
- Familiarity with computer data entry.
- Accurate typing skills of at least 40 words per minute.
- Accuracy rate of 92% for Level I and II positions and 95% for the Coding Specialist position.
- Strong verbal and written communication skills.
- Ability to work overtime or additional shifts when required.
Location
Indiana, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
Yes
Posted
3 months ago