SUMMARY
This position accounts for the accuracy of diagnosis and procedural coding to ensure the highest level of coding is being performed while maintaining compliance with governmental and other payers for coding and billing purposes. Reports to the Manager of the Health Information Management (HIM) Department.
DUTIES/RESPONSIBILITIES (include but are not limited to the following)
- Audit, abstract and code data collected from patients medical records using ICD-10CM/PCS, CPT, and or HCPCS, in accordance with coding guidelines.
- Review narrative records of patient treatments and surgical procedures to determine what information is appropriate for coding purposes (i.e., operative reports, outpatient infusions, ER reports, etc.).
- Enter coded medical record data into applicable electronic health record system(s).
- Serves as a resource to other hospital personnel for coding items.
- Contact provider, nurse, laboratory, and other auxiliary personnel for information needed to complete, correct, or clarify medical records and/or resolve discrepancies.