Job Description

Health Information Management

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records.

Job Responsibility

1. Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.

2. Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.

3. Utilizes resources and reference materials (e.g., on-line sources, manuals) to identify appropriate codes and reference code applicability, rules and guidelines.

4. Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record.

5. Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures.

6. Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.

7. Makes determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process.

8. Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment.

9. Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations.

10. For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.

11. Assigns appropriate discharge physician in the system.

12. Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations.

13. Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations.

14. Completes standardized tasks that are guided by policies, procedures, guidelines and precedent to provide ongoing function support.

15. Makes routine and few non-routine decisions with some latitude, but still subject to approval.

16. Ensures timely and accurate performance of responsibilities; produces quality results with work frequently reviewed.

17. Elevates questions, problems and significant challenges to more senior team members for direction or subject matter expertise on new or unprecedented assignments.

18. Performs related duties, as required.

Job Qualification

High School Diploma or equivalent required.

1-3 years of technical experience, required.

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