- Codes outpatient charts and/or professional charts and abstracts all required data from records according to established procedures; including medical necessity for Medicare charts.
- Uses ICD-10 CM/PCS/CPT-4/chargemaster to code all diagnoses, operative procedures and physician procedures performed for outpatient procedures.
- Verifies/changes levels of care provided according to level of care guidelines.
- Captures all missing records and documentation, i.e. IV start/stop times, etc.
- Interacts with physicians and physician's offices regarding diagnoses or coding questions.
- Performs other work as needed to help within the department.
- Keeps current with coding practices and skills through in-services, seminars, workshops and current literature to increase coding knowledge.
- Reviews the entire medical record for identification of all documented conditions, diagnoses and procedures.
- Demonstrates the ability to read physicians handwriting and interpret diagnostic and therapeutic information.
- Attends and participates in departmental meetings.
Must be a high school graduate or equivalent. College education with an RHIT, RHIA, CCA, CCS, CPC, COC, CMC or CIC credentialed, or equivalent experience required. Must have comprehensive knowledge of ICD-10, CPT and HCPCS codes. Two (2) years coding preferred. Experience with computerized record abstraction systems preferred.
