Reviews medical record content and codes using ICD-9-CM (soon to be ICD-10). Performs various clerical duties as assigned and contributes to efficient functioning of the department.
Coding Inpatient and Discharge Information:
Reviews all pertinent medical record information to code records accurately.
Determines if there is sufficient information in order to code medical records. Notifies appropriate staff if a medical record must be completed in order to code it.
Appropriately queries physicians, as needed, for more specific information to code to the highest level of severity or chronicity.
Codes medical records daily on the unit and in the HIM department in order to code yesterday's discharges, medical records identified as uncoded on the Billing Readiness Report and any additional medical records requested to be coded/reviewed.
Assists with timely processing of charts.Maintains charts in the discharge processing file.
Reviews coding clinics as needed, when coding changes occur.
Maintains credentialing (CEU's) as required, if applicable.
Identifies any missing or inappropriate documentation within a patient's record.
Ensures all papers have the patient's name and medical record number.
Ensures documentation is legible for coding and auditing purposes.
Continually seeks to increase competency in performing duties and maintains current standards and practices for coding functions.
Attends department meetings/webinars and complies with all hospital and departmental trainings.