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Form of workJob Summary: The Junior Coder is responsible for coding medical records, including all diagnoses and operative and diagnostic procedures in patient medical records, using the current International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedures Coding System (HCPCS) and entering coded information into an automated grouper system. Does related work as required.
Responsibilities:
- Using the current HCPCS, ICD and CPT coding system, assigns and records an accurate code to all diagnoses, procedures, and operations as documented by the attending physician in the indicated patient's medical record.
- Ensures that all factors necessary for assigning an accurate DRG are present, and that all diagnoses are ranked properly.
- Makes appropriate contacts in order to acquire or clarify necessary information.
- Enters final diagnostic code numbers and narrative descriptions of diagnoses and procedures into an automated grouper system.
- Provides information to and responds to inquiries regarding medical documentation and DRG's from hospital staff, including utilization and quality assurance staff, patient accounts staff and the Risk Manager.
- Abstracts information from medical records to compile reports and statistical information.
- Enters data such as diagnosis, treatment, admission and discharge dates, and length of stay on hospital-wide or regional automated database.
- Participates in other medical records functions, as assigned.
Qualifications/Requirements:
Experience: The Junior Coder should have either of the following: (a) the CPS, CPC-A, COC, CCS or CCS-P credential; or (b) two years of experience where the primary function of the position was working with medical records in a health care setting; or (c) satisfactory completion of at least 30 college credits* which included courses in medical terminology and ICD medical records coding or at least six credits* in anatomy and physiology; or (d) satisfactory completion of a college certificate program in medical records coding of at least 30 credits* or (e) a satisfactory equivalent combination of the foregoing training and experience but which must include the specialized coursework in medical terminology and ICD medical records coding or 6 credits* in anatomy and physiology.
Education: High school or equivalency diploma, required.
Licenses / Certifications: CPC, CPC-A, COC, CCS or CCS-P credential, preferred.
Other: Good knowledge of medical terminology; working knowledge of the principles of the medical record system and its operation; working knowledge of the current HCPCS, CPT and ICD codes; ability to understand and code medical records; ability to communicate effectively both orally and in writing; ability to effectively use computer applications such as spreadsheets, word processing, calendar, e-mail and database software in performing work assignments; ability to read, write, speak, understand, and communicate in English sufficiently to perform the essential duties of the position, thoroughness; sound judgment; tact; discretion; initiative; accuracy; physical condition commensurate with the demands of the position.
