Responsible for abstracting and analyzing clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.
• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system outpatient (OP)/emergency department (ED) or observation short stay.
• Oversees and reviews provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures.
• Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.
• Ensures accurate coding by clarifying diagnosis and procedural information through a query process.
• Assigns Present on Admission (POA) value for inpatient diagnoses.
• Ensures accurate physician name against each service and accurate time and date.
• Interacts with physicians and other areas when additional coding information is needed; for example to prevent medical necessity denials.
• Prepares and reviews documentation to verify and when necessary, correct the patient disposition upon discharge.
• Maintains the assigned target of production and accuracy of Coding.
• Prioritizes work to ensure the timeframe of medical record coding meets regulatory requirements.
• Engages with the physicians in the Coding Query process and provides training as necessary.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
Accountabilities
• Ensures that codes are assigned correctly and sequenced appropriately as per government and insurance regulation
Experience :-
Required:
• 3 years of relevant progressive experience in a similar role.
Desired:
• Experience in a large healthcare facility
Educational Qualification: Required:
• Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare
Desired:
• N.A.
Job details are sourced from the employer's original posting.
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