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Practice Medical Records Coder
Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records.
- Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
- Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record.
- Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures in accordance with the established International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM), International Classification of Diseases 10th Revision Procedure Classification System (ICD-10-PCS) Official Guidelines for Coding and Reporting.
- Reports a discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.
- Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection.
- For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.
- Assigns appropriate discharge physician in the system.
- Analyzes medical records for completeness of documentation and contacts physicians for clarification for any incomplete/ambiguous or conflicting documentation.
- Assist in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, and resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and occurrence of events.
- Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations.
- Maintains the minimum data standards for accuracy and productivity as defined by the facility.
- Performs related duties, as required.
- Associate Degree or related field, required. Bachelors preferred OR Successful completion of a medical coding course sponsored by the health system, required.
- Minimum of one (1) year experience as an ICD-10 medical records coder, preferred.
- Familiarity with an automated medical record tracking systems.