Overview
Under supervision, to perform work involving the thorough examination and evaluation of medical record documentation to accurately assign ICD-10-CM, CPT 4, and HCPCS codes and to abstract relevant information from inpatient and outpatient records.
Responsibilities
PRINCIPAL DUTIES AND RESPONSIBILITIES(*Essential Functions)
Coding Standards and Guidelines: Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. Completes HealthStream coding compliance task.
Coding: Applies the appropriate diagnostic and procedural codes to individual patient health information, for data retrieval, analysis, and claims processing utilizing computerized encoder and grouper.
Accuracy Standards: 100-95 = Exceeds Standards (5); 94-90 = Above Standards (4); 89-85 = Meets Standards (3); 84-80 = Improvement Needed (2); 79 and under (1) - Most work onsite with supervisor, until successful completion of a quarterly review with accuracy level at "meets standards".
Abstracting: Applies appropriate elements to record, including admitting provider, attending provider, other providers, point of origin, primary service, discharge destination, discharge disposition, present on admission.
Accuracy Standards: 100-90 = Exceeds Standards (5); 89-80 = Above Standards (4); 79-70 = Meets Standards (3); 69-60 = Improvement Needed (2); 59 and below: (1) must work on site, with supervisor, until successful completion of a quarterly review, with accuracy level at �meets standards�.
Coding Education Maintenance: Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department director for resolution, Completes educational credits according to applicable area.
Learning opportunity standard: 8 or more completed = Exceeds standards (5); 7-6 completed = Above standards (4); 5-4 completed = Meets standards (3); 3-2 completed = Improvement needed (2); 1-0 completed = Not meeting expectations (1).
Queries: Queries the appropriate discipline for additional or clarifying documentation to ensure the accuracy and completeness of coding and abstracting.
Teamwork: Shows initiative by providing input to better the department and/or hospital. Reviews MCC and CC list to identify opportunities for queries or documentation improvement.
Departmental Expectations: Attends departmental meetings (6 out of 12 monthly meetings minimum). Acknowledges minutes and handouts, when absent from meetings, by initialing e-mail within one week. Checks Methodist's internal e-mail when logging on for work, at mid-day, and before logging off.
Qualifications
JOB SPECIFICATIONS(Minimum Requirements)
KNOWLEDGE, SKILLS, AND ABILITIES
- Considerable knowledge of ICD-10 and CPT coding systems.
- Ability to work independently, and as part of a team collaborating with colleagues.
- Enthusiastic, motivated and positive attitude.
- Successful completion of a coding certificate program, with American Health Information Management Association (AHIMA) approval status, as RHIA, RHIT, CCS or CCA is required.
EDUCATION
- High School Diploma/GED Equivalent Required
- Certificate Required
- 5 Healthcare/Medical - Medical Coding Preferred
STANDARDS OF BEHAVIOR Meets the Standards of Behavior as outlined in Personnel Policy and Procedure #1, Employee Relations Code.
CONFIDENTIALITY/HIPAA/CORPORATE COMPLIANCE Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family, organizational and other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state and local laws, rules and regulations governing ethical business practices for healthcare providers.
DISCLAIMER - The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. The statements are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required.