The 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 10 CM/PCS) for diagnoses and procedures, and entering coded information into an automated grouper system. Does related work as required.
Responsibilities:
Using the current ICD10 CM/PCS coding systems for diagnoses and procedures, 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.
Abstracts information from medical records to compile reports and statistical information.
Enters data such as diagnosis, treatment, admission and discharge dates, length of stay, etc., on hospital-wide or regional automated database.
Query appropriate provider as necessary regarding documentation of diagnosis and/or procedure.
Qualifications/Requirements
Experience:
Minimum of one year of experience where the primary function of the position was inpatient medical records coding in or for a hospital.
Education:
High school or equivalency diploma, required. An Associate's degree or Bachelor's degree in health information management may be substituted for one year of the required experience.
Licenses / Certifications:
Current certification is Certified Coding Specialist (CCS) required. Other:
Thorough knowledge of the current ICD10CM/PCS diagnosis and procedure codes; thorough knowledge of medical terminology, anatomy and physiology; ability to understand and code medical records; ability to communicate effectively both verbally and in writing; ability to effectively use computer applications or other automated systems such as spreadsheets, word processing, calendar and e-mail for performing work assignments; ability to read, write, speak, understand, and communicate sufficiently to perform the essential duties of the position. Special Requirements: N/A
