JOB SUMMARY: Abstracts clinical information from medical records. Assigns appropriate ICD-10-CM and CPT-4 codes.
QUALIFICATIONS:
JOB SPECIFIC CORE COMPETENCIES:
- Aptitude for detail and accuracy.
- Ability to work unsupervised.
- Ability to abstract relevant clinical and demographic information from the medical record for highest specificity of coding and reimbursement purposes.
- Has a good foundation of ICD-10-CM and CPT-4 coding and reimbursement guidelines.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
- Assigns ICD-10-CM and CPT-4 codes in accordance with coding and reimbursement guidelines including, but not limited to, the following:
- Identifies principal and secondary diagnoses and procedures based upon UHDDS standards.
- Uses seventh character and sequencing conventions.
- Documentation is present to substantiate codes assigned.
- Abstracts relevant clinical and demographic information from the medical record.
- Serves as a coding resource for Patient Financial Services.
- Refers coding and system questions to the Director/Supervisor in a timely manner for determination and guideline development.
- Assists in abstracting of data for selected studies when applicable
- Keeps current on coding guidelines, rules and regulations, and new codes.
- Remote coding agreement signed and approved by Director.
- Other duties as assigned.
EXPECTED BEHAVIORS:
- Accuracy:
- Accurately codes all diagnoses and procedures measured by Coding Quality Audits.
- 97 percent of all records for which the associate is responsible for must be coded accurately to maximize DRG/APC weight.
- Productivity Level:
- Laboratory/Radiology coding: 2 minutes/record;
- Provider Office Visits: 2 minutes/record;
- Recurring Patient Visits: 3 minutes/record;
- ED/Urgent Care coding: 5 minutes/record;
- Recurring Oncology: 5 minutes/record.
- Productivity Calculation:
- Laboratory/Radiology coding: 2 mins/record x__________charts
- Provider Office coding 2 mins/record x __________charts;
- RCR coding: 3 mins/record x__________ charts;
- ED/Urgent Care coding: 5 mins/record __________charts;
- Recurring Oncology: 5 mins/record x __________.
- Using productivity levels above, calculate hours produced and divide by hours worked. 95 - 100 percent – 2; 80 - 94.99 percent - 1; <80 percent - 0;
- Abstracted information and codes are accurately keyed into the computer abstracting system. 97-100 percent – 2; 90-96.99 percent – 1; <90 percent – 0.
- Coded accounts are monitored to assure required fields for each patient type are consistent and complete.
- Corrects appropriate coding and abstracting discrepancies.
- Assists Patient Financial Services in clarification of coding vs. reimbursement issues.
- Seeks assistance only after referring to own resources.
- Keys abstracted information for selected studies.
- Confirms completion date/time for data entry and reports.
- Assures accuracy of all abstracted information.
- Generates reports as requested.
- Demonstrates ability to embrace and adapt to change.
- Regularly initiates ideas to improve the efficiency and processes of the department in a positive and productive manner by attending at least 90 percent of monthly departmental meetings.
- Keeps current on coding guidelines, rules and regulations, and new codes.
- Maintains productivity and accuracy standards in order to continue remote coding privileges.