Responsible for timely and accurate processing of all Inpatient visits. Codes and abstracts all CMH patients following established coding guidelines and utilizes ICD-9CM and CPT-4. Follows policies and procedures to ensure accurate and timely workflow. The position actively supports the Hospitals and the departments Continuous Quality Improvement and customer service goals, individually and as an effective team member.
1. Maintains work performance statistics, self monitoring productivity.
2. Codes and abstracts inpatient records to support the type and level of services performed including determining the appropriate CPT codes, consistent with physician documentation in medical record.
3. Searches for missing and/or not received reports.
4. Interprets the complex services rendered by subspecialty physicians into optimal coding language and prices. Determine diagnosis code(s) based on documentation and tracks any inconsistencies/trends.
5. Investigates uncodeable diagnosis. Identifies issues to help the organization effectively manage inpatient process for chart completion and to support reimbursement.
6. Resolves issues with cancelled admissions, failed visits, incorrect patient types and incorrect admission/discharge dates with Admitting and Patient Financial Services. Makes appropriate corrections on systems and reports/lists and/or forward to the appropriate person for resolution.
7. Performs daily, weekly, and monthly reconciliation process accurately and in a timely manner.
8. Assists in training and orientation of new employees.
9. Assists with testing and implementation of systems/product changes and upgrades.
10. Ensures JCAHO compliance with IM standards in clinical information management.
1. A registered health information administrator (RHIA), accredited health information technician (RHIT) or Certified Coding Specialist (CCS) or Certified Coding Professional (CCP) is required.
2. One to three years prior coding experience in the health care information management industry. Must maintain credential status through continuing education requirements. Incumbent must also maintain up-to-date on coding changes and requirements.
3. Ability to handle multiple projects. Ability to appropriately prioritize tasks. Ability to cope with the inherent pressures of a results deadline oriented position.
4. Must be able to deal effectively with all CMH staff – clinical, clerical, management. Excellent communication skills necessary for interaction at all levels of staff and with physicians.