Codes and abstracts medical records for the purpose of reimbursement, research, and compliance with federal and state regulations and accrediting agencies. Using ICD-10-CM and CPT-4 classification systems, assigns Diagnosis Related Groups (DRG) for appropriate financial classes. Performs analysis of the records to assure completeness of documentation.
DUTIES AND ESSENTIAL FUNCTIONS
Overall performance rating of below indicated essential job duties:
Codes and sequences diagnosis and procedures from hospital medical records using 3M/360 Encompass CAC (Computer Assisted Coding) ICD-10-CM classification system
Codes and sequences diagnoses and procedures from emergency department and other outpatient records for billing purposes and data retrieval using the 3M/360 Encompass CAC ICD-10-CM and CPT-4 classification system
Review medical records for completeness and abstracts and codes clinical data such as diseases, operations procedures and therapies
Performs quantitative and qualitative analysis on medical records according to standards established by the Medical Records Committee, the Joint Commission, and other licensing agencies
Interacts with physicians to ensure accurate assignment of ICD-10-CM and CPT-4 codes
Works any shift necessary for the adequate coverage of the department and additional hours if needed