About This Role
This union position involves reviewing and evaluating in-patient and out-patient medical health records to extract pertinent diagnostic, procedural, and demographic information. The Medical Coder ensures proper assignment and maximization of financial reimbursement through the correct interpretation and application of coding rules and regulations, and the accurate selection, sequencing, and coding of diagnostic and procedural information. The role primarily involves coding from paper records, as the facility does not use electronic medical records.
Responsibilities
- Review, evaluate, and correctly code in-patient and out-patient medical records, extracting pertinent diagnostic, procedural, and demographic information
- Maximize financial reimbursement through proper interpretation and application of HCFA, ICD-10-CM, and CPT-4 rules and regulations
- Maximize financial reimbursement through correct selection, sequencing, and coding of diagnostic and procedural information
- Bring questionable or poorly documented cases to the attention of the physician of record, Medical Records Director, or Medical Director for discussion, clarification, and resolution
- Collaborate with and provide expert assistance to medical staff and medical records staff regarding coding and other related issues
- Work closely with billing unit staff to ensure appropriate internal control of data
- Verify information on the PSI abstract form and review additional information recorded on the PSI abstract form
- Utilize computer systems in determining health care coverage for each patient
- Ensure that health care records are coded, abstracted, and forwarded to the billing unit for billing purposes
- Be responsible for maintaining a weekly "status" log of all admissions, transfers, and discharges so that all records are accounted for and completed
- Recognize the highly confidential information in a medical health record and understand the need for, and importance of, maintaining strict confidentiality of all patient and hospital information at all times
- Assist supervisor and medical staff in other related work as requested
Requirements
- Medical Coding certificate
- ICD-10 certified
- Extensive working knowledge of medical terminology, anatomy, physiology, and pathology
- Knowledge of pharmacology, diagnostic testing, and medical procedures sufficient to allow accurate interpretation of medical record content and determination of precise diagnoses and procedures
- Complete working knowledge and understanding of ICD-10-CM and CPT-4 classification systems
- Demonstrated proficiency in the application of coding rules and regulations
- Knowledge of Medicare, Medicaid, and other third-party payors' regulations and policies regarding billing and reimbursement
