ROLE SUMMARY

Medical Record Coder is responsible for timely review of patient records in order to identify an appropriate selection of codes which accurately reflect the reason for admission, extent of care received and level of severity of illness.    Coder is further responsible for insuring that all data elements required for federal and state report are collected in included in the patient’s demographic record.

CORE RESPONSIBILITIES

1.            Selects appropriate assignments for coding/abstracting from work queue.  Uses the 3M encoder and CPT-4 coding systems to accurately code diagnosis and procedures for all ancillary patient encounters.  Abstracts designated statistical data from the patient record and enters the information into the abstract database.  Selection/sequencing of principal and secondary diagnosis done correctly at least 98% of the time.  Meets minimum standard productivity requirements as outlined in the coding productivity expectation policy. 

2.            Contacts physician and/or ancillary departments when additional information is needed to accurately code the record.   Strives to decrease pending accounts on all patient types.

3.            Completes record or reassigns record to appropriate work queues 100% of the time.  Maintains patient, medical record, department and employee confidentiality at all times.

4.            Successfully completes all McStrategies lessons as assigned and attends audio seminars to fulfill coding in-service training and CEUs.

5.            Attends and participates in department meetings.  Is responsible for all information communicated at the meetings.   Attends all mandatory hospital meetings and training.

SKILLS, KNOWLEDGE, AND ABILITIES

•     Demonstrated proficiency in accurately coding ancillary tests using ICD-9-CM and CPT coding.

•     Ability to converse clearly and concisely in a professional manner.  Detail oriented and self motivated individual. 

•     Experience with personal computer and mainframe applications and with use of clinical encoders and groupers.

•     Sitting for an estimated seven hours per day with periodic interruptions.

•     Knowledge of anatomy, physiology, and medical terminology.  Knowledge of coding practices and guidelines, rules and regulations, and coding ethics.

•   Strive to decrease pending accounts while maintaining coding quality, accurate reimbursement and compliance

MINIMUM REQUIREMENTS

•      Successful completion a coding course. 

•      Coding and abstracting experience in ICD-9, CPTs, including modifiers and APCs.

•      Proof of successful completion of anatomy, physiology, and medical terminology.

•      RHIT or CCS preferred.

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