Health Information Technician

Coder/Abstractor

The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing. Responsible for concurrently and retrospectively coding inpatient, outpatient (Observation) (Surgical Day Care), Emergency Department, physician clinic, hospitalist accounts, and ancillary medical records and abstracting information into the hospital information system. Will also be responsible with assisting other Revenue Cycle functions as needed.

Assist Utilization Review with concurrent coding of inpatient/outpatient medical records utilizing the ICD Code book. Responsible for the final coding of all CRH physicians, hospital, CMC and LTCC medical records utilizing: ICD, CPT Code, and HCPCS coding books, the 3M encoder and the computer system. Provides ongoing education and follow-up to physicians regarding E#M coding levels and medical necessity guidelines. Identifies services and procedures provided but not adequately documented in the health record. Advises the department director of documentation deficiencies. Identifies trends and ongoing problems related to medical documentation and recommends possible solutions. Responsible for abstracting designated medical records information into the computer system (may include, but not be limited to, verifying that the discharge status is correct, name of anesthesiologist on surgical cases, referring and consulting physicians, blood and blood products codes, diagnosis codes, surgery date and type of anesthesia administered, and procedure codes). Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. Monitors unbilled accounts for outstanding or uncoded visits to reduce accounts receivable days for all patients. Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to the director for resolution. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. Analyze records for Medical Staff quality indicators. Maintains data, department activities, and all patient information in a confidential manner. Consistently follows established procedures. Assists with Revenue Cycle duties which include but are not limited to charge review, reporting, assisting CDI and organizational education. Other duties as assigned.