|Facility:||St. Joseph Regional Health Center (Bryan)|
|Department:||SJH MEDICAL RECORDS|
|Shift:||Monday - Friday|
Interprets health record documentation using knowledge of anatomy, physiology, pathological processes of disease, and medical terminology to code and abstract diagnoses and/or procedures for inpatient and outpatient cases. Resolve errors/pre-bill edits associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors.
Required: High school diploma or equivalent (GED)
Preferred: Bachelor's degree (e.g. BA, BS, BSN, BSW)
Required: Successful completion of a Coding Certification program through AHIMA or ACCP; or equivalent training acquired through at least two years of progressive on-the-job experience and working towards obtaining Coding Certification
Preferred: CCS, CPC, RHIA, RHIT
- 1.ASSIGNS ICD-9-CM, CPT AND OTHER CODES TO DIAGNOSES AND PROCEDURES TO ENSURE ACCURATE RECORD OF SERVICES PROVIDED: Reviews medical records to determine the principle diagnoses and relevant procedures and accurately assigns ICD-9-CM, CPT and other codes to records in accordance with established guidelines. Utilizes technical coding principles and MS-DRG reimbursement expertise to assign appropriate ICD-9CM diagnoses and procedures. Communicates with physicians in a professional and timely manner in order to obtain additional information required for accurate coding. Extracts required information from source documentation and enters into encoder and abstracting system. Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge. Assigns present on admission (POA) value for inpatient diagnoses. Indentifies non-payment conditions (HAC) and when required, report through established procedures. Assist in implementing solutions to reduce back-end billing errors.
- 2.ABIDES BY THE STANDARDS OF ETHICAL CODING AS SET FORTH BY THE AMERICAN HEALTH INFORMATION MANGEMENT ASSOCIATION (AHIMA):Demonstrates behavior that reflects integrity, supports objectivity, and fosters trust in professional activities. Complies with official coding rules and guidelines to ensure high quality health information and accurate claims submission. Protects data integrity and validity. Respects patient confidentiality for accessing and disclosure of health information. Brings identified potential coding compliance concerns to the Director of Health Information Management or Coding Supervisor for resolution.
- 3.SERVES AS A RESOURCE TO OTHER DEPARTMENTS AND CODERS TO PROVIDE BACKUP FOR CODING ALL TYPES OF CASES AND ANSWER CODING RELATED QUESTIONS: Serves as a resource person for the Health Information Management (HIM) Department as well to other entities within the St. Joseph Health System by responding to coding related issues in a professional manner. When necessary, educates health care providers regarding reimbursement methodologies, documentation rules and regulations related to coding. Pursues ongoing continuing education in the areas of coding and abstracting.
- 4.DATA QUALITY AND MANAGEMENT: Participates in the development of coding policies and procedures as identified. Reviews the accuracy of abstracted data elements for data base integrity and claims processing. Abstracts pertinent information from patient records, including the discharge disposition, universal indicators, and consultants. Actively supports the implementation of the Malcolm Baldrige management framework for performance excellence to maintain quality and safe patient care. Maintains productivity and quality standards.
- Performs other duties as assigned to meet the organization`s needs.