Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance
Knowledge of an electronic medical record and imaging systems
Working knowledge of medical terminology, anatomy and physiology
Proficiency with electronic encoder application
Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
Interacts and communicates effectively with members of the coding team and the appropriate stakeholders.
Participates and provides good feedback during coding section meetings and coding education inservices as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders.
SERVICE ESSENTIAL FUNCTIONS
Responds promptly to internal and external customer requests. Responds promptly and appropriately to requests to code or review coded accounts for accuracy.
Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
Responsible for assigning diagnostic and procedural codes to encounters of high complexity.
Maintains and achieves departmental standards of coding quality by assigning accurate ICD-10-CM/ICD-10-PCS and CPT codes and APC assignment utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
Maintains and achieves departmental standards of abstracting quality by reviewing the discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.
Reviews medical record documentation and abstracts data into the encoder and Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures. Utilizes all tools/resources for accuracy.