Inpatint Coding Job Details:
JOB
DEFINITION: Under
limited supervision, reviews medical records and performs coding on all
diagnoses, procedures, (both medical and surgical), and assigns the correct
diagnostic related grouping (DRG). Uses the most accurate codes for
reimbursement purposes, research, epidemiology, statistical analysis outcomes,
financial and strategic planning, evaluation of quality of care, and
communication to support the patient’s treatment. Maintains the confidentiality
of patient records and procedures.
ESSENTIAL
FUNCTIONS: The
following duties ARE NOT intended to serve as a comprehensive list of
all duties performed by all employees in this classification. Shown are duties
intended to provide a representative summary of the major duties and
responsibilities. Incumbent(s) may not be required to perform all duties listed
and may be required to perform additional, position-specific duties.
REPRESENTATIVE
DUTIES: Responsible
for abstracting, coding, and sequencing the classification of medical and
surgical procedures, diagnosis, and treatment modalities on Inpatient and Day
Surgery records. Selects the most accurate and descriptive codes from the
listings of International Classification of Diseases, Ninth Revision, Clinical
Modification, (ICD-9-CM American Medical Association Current Procedural
Terminology (CPT-4) Coding system, and Healthcare Common Procedure Coding
System (HCPCS). Assigns DRG’s and performs coding compliance reviews. Abstracts
and codes pertinent medical data into multiple software programs. Follows
official coding guidelines to review and analyze health records. Maintains compliance
with both external regulatory and accreditation requirements, and with State
and Federal regulations. Extracts pertinent data from the patient’s health
record, and determines appropriate coding for reports and billing documents.
Identifies codes for reporting medical services, procedures performed by
physicians, and enters codes into computer system. Provides feedback and
education to physician and professional staff regarding changes in coding
methodology and enhanced documentation procedures for optimizing reimbursement.
Utilizes the coding query process to providers to
request missing information. Corrects records with inconsistent information
and/or containing discrepancies. Provides training and mentoring to new
employees as needed. Performs routine audits independently and participates in
performance improvement. Participates in coding compliance plans, research and
analysis, benchmarking, financial and strategic planning, and other customer
requested project. Reviews and discusses informational requirements with
individuals to determine the most expeditious method for data acquisition and availability
of data. Retrieves and compiles data for reports as directed. Maintains the
confidentiality of patient records and procedures. Performs other duties as
assigned or required.
