Analyze medical records and assign codes to classify diagnoses and procedures to support the reimbursement system, medical necessity, and compliance policies.
Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM/CPT codes for billing.
Perform internal and external reporting, research, and monitor regulatory compliance.
Accurately code inpatient/outpatient conditions and procedures as documented in the ICD -10- CM Official Guidelines for Coding and Reporting.
Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors.
Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for inpatient and outpatient encounters.
Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures.
Utilizes technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-10-CM diagnoses and procedures.
Assigns present on admission (POA) value for inpatient diagnoses.
Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge.
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
RHIA, RHIT, or CCS Certification, EMR/EHR Experience, Multi-tasking, Listening, Verbal Communication, Three years hospital coding experience preferred.
A Fully Integrated Health System.