Employment Spot

Job Description

Job Summary:  This job is responsible for reviewing discharge abstracts, patient charts and other medical records in order to assign the appropriate codes to diagnoses, diseases, procedures and other resources used for patient care.  An incumbent accurately codes medical records of the emergency department, outpatient visits, inpatients, observation and ambulatory cases to capture the services rendered and thus ensure that the MBO receives accurate reimbursement.  This is the journey level of the job family wherein an incumbent is fully conversant with coding conventions and MBO standards/procedures for the health information management function.  Accuracy is critical for satisfactory job performance, and incumbents are held to a 95% accuracy rate.  Essential Duties:  

• Assigns appropriate ICD-9-CM and CPT-4 codes via the encoder.
• Identifies the principal diagnoses for each DRG patient and sequences diagnoses in order to assure appropriate DRG assignment.
• Identifies physician responsible for attesting to the principal and secondary diagnoses and procedure selected for DRG assignment.
• Abstracts clinical information from medical records.
• Functional knowledge of the STAR Financial System in the Patient Administration and Patient Accounting menus.
• Composes queries to the attending physician with input of the Coding Supervisor for documentation clarification.
• Researches and responds to Regional Business Office questions with minimal assistance from the Coding Supervisor.
• Demonstrates basic knowledge of guidelines published in the Coding Clinic and the CPT Assistant publications.
• *The number of DRG inpatient records returned to the coder for DRG revisions do not exceed 5 per month. 
• *If assigned to inpatient and outpatient coding, meets established and published productivity targets of 27 records (***) per 8-hour shift with an accuracy rate of 95%.  If assigned to ancillary coding, exceeds by 35% the established and published productivity targets per 8-hour shift with an accuracy rate of 95%.  If assigned to ED coding, exceeds by 35% the established and published productivity targets of 120 ED visits per 8-hour shift with an accuracy rate of 95%.  ***Sliding scale productivity calculation adjustment recognizes cases with extended length of stay.

Job Requirements

Education:

• High school diploma or equivalent.
• Completion of a recognized course of study for health information practitioners or coding specialists preferred.

• One year of recent coding work experience in an acute hospital health information management department. 
• Employment by a contract coding company may be substituted or the experience requirement. 

• Certification (RHIA, RHIT and/or CCS) by the American Health Information Management Association is required.   Maintenance of certification required.

Additional Responsibilities:

• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
• Adheres to and exhibits our core values:
  Reverence: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
  Integrity: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
  Compassion: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community. Excellence: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
• Maintains confidentiality and protects sensitive data at all times.
• Adheres to organizational and department specific safety standards and guidelines.
• Works collaboratively and supports efforts of team members.
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.