Will review medical record documentation and accurately code the primary, secondary diagnoses and procedures utilizing federal and state guidelines to assure accuracy of coding both the ICD-9-CM and CPT-4 conventions. Sequences diagnoses and procedures accurately and appropriately. Verifies and accurately abstracts required data into the financial systems database.
This description is not intended to be a complete list of duties. Other related duties may be assigned.
Must test and pass CCA with a 93% in order to obtain the Level II Coder/ Abstractor. Through the testing process must, demonstrate a working knowledge of coding conventions and guidelines. Testing is allowed in 3 month intervals.
Will review the Emergency Room medical record documentation and accurately code the primary and secondary diagnoses and procedures using ICD-9-CM and CPT-4 coding conventions. Will sequence the diagnoses and procedures accurately using coding guidelines and conventions. Verifies Infusion charges with communication to the department if changes to the charges are needed. Resolves all encountered coding edits.
Performs comprehensive review of Emergency Room medical records and abstracts data from the medical records with reference to specific identified diseases following defined procedures. An audit chart processing, notes errors or omissions, and refers to appropriate staff when needed.
Follows up to complete any missing information preventing the chart from proceeding through the coding process. Maintains required records, files, and databases. Generates and compiles reports when needed. Must verify and correct patient status, patient discharge disposition, and any other information required.
A high school diploma or equivalent is required. Performs related responsibilities as requested.