GENERAL SUMMARY:
Using established coding principles and procedures reviews, analyzes and codes diagnostic and/or procedural information from the patient's medical record for reimbursement/billing purposes. Accurately abstracts information from the medical record for compilation of a patient database, which supports medical research projects, patient care evaluation and administrative decision making related to patient care. The coding function is considered a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement. The coding function also ensures compliance with established coding guidelines, third party reimbursement policies, regulations, and accreditation guidelines.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
1. Identifies all diagnostic and operative procedures and other pertinent patient stay data for Henry Ford Health System databases by thoroughly reviewing entire patient medical records, including histories physicals, operative reports, pathology reports, therapy notes nursing notes and discharge summary, etc. Verifies and/or requests documentation to support compliance.2. Assigns diagnostic and procedural codes in accordance with coding principles and established guidelines utilizing encoder software.3. Identifies appropriate principal diagnosis and sequences all secondary diagnoses and procedures according to guidelines of the MS-DRG reimbursement system (applicable to all patients). Applies knowledge of optimization in MS-DRG assignment.4. Verifies completeness of medical record within electronic medical record, reporting any discrepancies to supervisor.5. Completes the discharge abstract by gathering pertinent patient stay data from record in addition to coded diagnostic and procedural data.6. Performs other related duties as required.7. If participating in the remote coding program, required to adhere to the Remote Coding Program Policy8. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, the Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
EDUCATION/EXPERIENCE:
Degree in Medical Record Sciences preferred but not required or successful completion of a certification program with certification as a Registered Health Information Technician (RHIT), Registered Health Administrator (RHIA), CCS Certified Coding Specialist or CCA Certified Coding Associate. If RHIT, RHIA certification eligibility certification must be obtained within six (6) months of employment and a signed statement attesting to this agreement must be obtained upon hire. Must have a thorough knowledge of anatomy, physiology, pathophysiology, disease processes, medical terminology, pharmacology, and coding systems. Prior coding experience preferred but not requiredCERTIFICATIONS/LICENSURES REQUIRED: RHIA, RHIT, CCS or CCA certification#LI-VD1
