Address
Form of workJOB PURPOSE OR MISSION:Performs quality audits on coding and abstracting.
JOB FUNCTIONS
ESSENTIAL JOB FUNCTIONS include, but are not limited to:
1. Performs quality audits to ensure the accuracy of coding and DRG assignment.
PERFORMANCE STANDARDS:
Audits both inpatient and outpatient records coded by staff.
Reviews charts for correct principal diagnosis and procedures.
Reviews charts for complications, co-morbid conditions, other diagnoses and significant procedures that require coding to ensure appropriate DRG assignment.
Audits records and notes documentation deficiencies.
Maintains a current knowledge of applicable codes and changes in codes/or procedures to ensure correct billing.
Performs audits in accordance with the official coding guidelines, coding conventions, coding clinics, CPT assistants, etc.
Audits abstracting elements including attending physician, procedural physician/date of procedure, consulting physician, anesthesiologist/date of anesthesia, discharge disposition
Audits the charging performed by the coder for ER, OBS and express care.
Monitors the work performance of the new employee during the probationary period.
Performs focus audits related to new procedures/technology and/or where coding concerns have been identified.
Provides regular feedback to the Coding Supervisor/Manager on employees in training.
Rolls up monthly and quarterly reports to reflect individual coder accuracy and group accuracy rates.
2. Identifies and codes records for the purpose of reimbursement, data analysis, research and compliance with federal regulations.
PERFORMANCE STANDARDS:
Production codes as needed.
Demonstrates a complete understanding of all guidelines concerning the coding and the sequencing of diagnoses and operations/procedures.
Codes discharge records in order of priority as assigned by the supervisor.
Inputs data into computerized health information system.
Demonstrates a thorough working knowledge of the medical coding systems.
Maintains control procedures to assure accuracy and completeness of coded information
3. Performs all other duties as assigned
EXPERIENCE REQUIREMENTS
Six years coding experience preferred.
SPECIAL SKILL, LICENSE AND KNOWLEDGE REQUIREMENTS
CCS (Certified Coding Specialist), or RHIT (Registered Health Information Technician), or
RHIA (Registered Health Information Administrator)
HIPAA REQUIREMENTS:
Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records w/out limitation both paper and electronic, patient demographics, patient information related to surgery or appointment schedules, information related to patient location, religious beliefs, lab or radiology results, medical records related to quality/data, patient financial and/or 3rd party billing, patient complaints, research information, investigatory information.
SAFETY REQUIREMENTS:
Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, PPE (?? Not sure if this is right), exposure control plans, hand washing, environment of care.
