Identifies and sequences all diagnoses and procedures, assigns ICD-10-CM and CPT-4 Codes and assigns a final DRG to all inpatient medical records at the time of discharge.
- Identifies and sequences all diagnoses and procedures. Assigns ICD-10 and CPT-4 codes and assigns a final DRG to all inpatient medical records at the time of discharge.
- Reviews inpatient and outpatient records to ensure complete and accurate documentation to support all diagnoses and procedures and follows-up until all documentation is received.
- Accurately abstracts required data such as discharge dispositions, consultations and procedure/operative information with 95% accuracy.
- In a 7.5 hour day, completes an average of 17-21 inpatient records, 50 surgical records, or 100 ED records.
- Inserts appropriate staging forms into medical records of newly diagnosis cancer patients.
- Uses Computer Assisted Coding as a tool to accurately code diagnoses and procedures.
- Reviews Risk of Mortality and Severity of Illness indicators and appropriately abstracts data for Clinical Documentation Improvement.
- Queries physicians appropriately and timely reviews the responses received in the coding queue.
High School graduate or equivalent with training in medical terminology and medical coding.
Minimum one year medical records coding experience required.
Licenses and Certifications:
CCS required within 1 year of hire.
Required Knowledge and Skills:
Medical record coding knowledge including analysis and abstracting. Strong professional, organizational, and interpersonal skills to effectively relate with all members of the healthcare team.
Normal office environment.
No expected exposure to blood and/or body fluids.
Sitting – Continuously
Standing/Walking – Rarely
Kneeling/Stooping – Rarely
Bending/Climbing – Rarely
Reaching above shoulder, at waist or below waist – Rarely
Lifting/Pushing or Pulling up to 40 pounds – Rarely
Lifting/Pushing or Pulling over 40 pounds – Rarely
Typing/Filing – Continuously
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
At CentraState, we welcome and promote the diversity of our employee family! Each unique person contributes to the overall success of this organization. Our inclusive culture fosters an environment of professionalism and respect for personal differences.
Additionally, CentraState Healthcare System prohibits discrimination based on arbitrary consideration of such characteristics such as race, color, religion, national origin, ancestry, gender (including pregnancy), affectual or sexual orientation, gender identity or expression, marital status, age, physical or mental disability or limitation, medical condition, genetic information, or veteran or military status, as well as any other legally protected class of persons and acts, in accordance with applicable State and Federal laws.