Assign special classification codes to each diagnosis and procedure performed, relying on knowledge of disease processes to assure that the proper classification code is assigned. May utilize classification software to assign codes and group to payment classifications to determine the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system. Use other coding systems, such as but not limited to APR-DRGs and the District of Columbia Medicaid system.
NATURE AND SCOPE:
Interact internally with staff, physicians, Hospital and University officials and the general public. Interact externally with physicians,
- Determine appropriate statements of principle diagnosis, secondary diagnosis, and procedures to be entered as a part of the medical record.
- Abstract diagnoses and procedures from the medical record using data from the entire medical record including but not limited to the history & physical, physician progress notes, discharge summaries, orders, emergency service records, consultation reports, results of diagnostic tests and operative reports.
- Translate diagnosis and procedure statements into ICD-10 CM/PCS and CPT-4 codes.
- Contact physicians when required documentation requires clarification due to its absent, incompleteness, inaccuracy or conflicting status at time of patient’s discharge.
- Generate a coding abstract for each coded medical record containing the optimized statement of diagnoses, procedures and the final Medicare Severity-Diagnosis Related Groups (MS-DRG) or All Patient Refined Diagnosis Related Group (APR-DRG).
- Verify and update medical and demographic data in the computer system as needed.
- Utilize classification software to assign codes and group to payment classification systems.
- Utilize coding worklists to ensure that workflow is adhered to according to Health Information Management policy.
- Achieve appropriate Hospital performance and productivity standards as established.
- Perform other duties that further the customer service needs of the unit, such as answering phones, greeting and escorting patients, and administrative and clerical duties upon demand.
- Respond to emergent and urgent patient and operational issues.
- Cover part or all of other shifts, and/or be on call.
- Obtain necessary certifications as required by regulatory agencies.
- Keep abreast of current Medicare/Medicaid regulations and ICD-10 CM/PCS and CPT coding principles affecting the Hospital reimbursement.
- Promote adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
- Attend annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
- Participate in activities that promote adherence to federal healthcare program requirements.
- Actively participates in Health Sciences Compliance Program activities.
- Adhere to the requirements of the HIPAA Privacy Policies and Procedures.
- Maintain confidentiality of patients, families, and staff.
- Perform other job-related duties as assigned.
- Knowledge of CPT-4 coding, ICD-9 CM/PCS and ICD-10CM/PCS coding and medical terminology.
- Knowledge of medical terminology, anatomy, physiology, and DRG reimbursement.
- Knowledge of Microsoft Word, Excel and PowerPoint.
- Ability to maintain a professional manner at all times.
- Ability to review medical records, abstract diagnosis and translate diagnosis into ICD-9 CM/PCS and ICD-10CM/PCS codes.
- Ability to successfully interact with physicians to obtain patient information, agreements as principle and for secondary diagnoses and procedures.
- Ability to work with a high degree of accuracy under time constraints to meet deadlines.
- Ability to exercise discretion and judgment in disseminating information.
- Ability to verify and update medical records in the computer database in an efficient manner.
- Competence in both oral and written English.
- Ability to establish and maintain effective and harmonious work relations with staff, physicians, Hospital and University officials, and the general public.
- Must demonstrate collaboration; accountability; respect; excellence; and service.
- Works with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors; looks for ways to achieve departmental/institutional results by partnering.
- Accepts responsibility for his/her actions to provide healthcare and or ancillary functions in a highly efficient and compassionate manner. The employee must function as a Steward (Have Ownership) of the Howard values that foster a commitment to improving the patient and student experience, organizational efficiency and the environment.
- Embraces diversity; cares holistically for those we serve; treats all as we would like to be treated; manages the patient’s right to privacy with meticulous care 100% of the time and keeps patient and proprietary information about the institution confidential.
- Anticipates the patient’s and student’s needs, presents as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experiences for our customers.
- Behaves in a friendly, resourceful and professional manner towards all they encounter; treats patients, students and visitors in the same way that they would want their family members or themselves to be treated
Associate’s Degree in related field or certified as a Registered Health Information technician (RHIT), registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS).
Two (2) years of experience in an acute care facility’s Health Information Management Department coding inpatient, ambulatory surgery, ambulatory care, emergency service diagnostic testing and therapy records utilizing ICD-10 CM/PCS , and CPT-4.