Job Description
Job Title: Medical Records Coding Analyst Job Code: 880215
Immediate Supervisor: Director Health Information Management
Status: Non-exempt
Department Function/Job Overview The Medical Records Coding Analyst is responsible for the inpatient and/or outpatient ICD-10-CM and PCS coding functions. Applies appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis and reimbursement of claims. Analyzes inpatient and outpatient medical records including laboratory and radiology requisitions and assigns codes for diagnoses, procedures and symptoms using a nationally recognized coding system, ICD-10-CM. Serves as a liaison between case managers, physicians, and therapists to clarify documentation to achieve accurate coding. Responsible for knowing Medicare and Medicaid regulations, as well as other payer requirements, regarding coding and documentation. Must be able to maintain strict confidentiality. Work will be performed in an ethical and legal manner following organizational policies, processes, and procedures. Responsible for quality service delivery and internal/external customer relations for Madonna as a whole, including upholding the mission and values for the department and facility.
Essential Functions (INFORMATION)
- Reviews medical record documentation, assigns, and verifies ICD-10-CM diagnosis and procedure codes for all inpatient and outpatient diagnoses and procedures.
- Utilizes an encoder to help ensure accurate and consistent code priority and DRG assignment, using all available references, edits and customized tips.
- Translates clinical documentation using knowledge of anatomy, physiology, disease process and medical terminology.
- Maintains disease and procedure indexes on all inpatients and outpatients by entering ICD-10-CM codes into the abstracting system.
- Contributes to the completion of the Inpatient Rehabilitation Facility â?? Patient Assessment Instrument by selecting and entering assigned data fields.
- Verifies that all medical records of admitted inpatients and registered outpatients are coded and abstracted.
- Assigns ICD-10-CM codes to symptoms and/or diagnoses from all laboratory and radiology requisitions and enters ICD-10-CM codes in abstracting system where appropriate.
- Reviews medical records concurrently and/or retrospectively and adds diagnosis and procedural codes to capture a complete picture of the patient's condition during their stay at Madonna.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines; Revises Madonna Rehabilitation Hospital Coding Guidelines as necessary to remain current and consistent with official coding guidelines.
- Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.
- Completes continuing education to obtain/maintain certification status.
- Assists with data collection and report completion for DRG analysis and qualifying diagnoses analysis.
- Assists with preparation of medical records for review by: 1) MRH supervisors, managers and committees; 2) MRH employees conducting quality assurance studies and research; 3) the Quality Improvement Organization; 4) external accrediting/licensing agencies (NDHHS, CARF, etc.); 5) external financial auditing organizations; 6) any other legitimate request.
(PEOPLE)
- Communicates with appropriate individuals regarding the results of documentation and coding quality reviews, including physician and therapist queries when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes; must be diplomatic and persuasive in presenting the expectation of timely, concise, thorough documentation of diagnoses and/or symptoms to support services rendered.
- Communicates with appropriate individuals regarding the results of other reviews including external providers of service; must be diplomatic and persuasive in presenting the expectation of good patient record documentation for compliance, customer satisfaction and revenue generation.
- Identifies learning opportunities and provides education to case managers, physicians and other clinicians based on coding and documentation reviews.
- Provides access to medical records to authorized individuals.
- Answers questions about the medical record content or patient stays at Madonna to authorized internal and external customers.
- Follows instruction from Manager to perform other functions as assigned in order to achieve the goals within the department.
(THINGS)
- Operates PC and software to review and/or enter master patient index information, diagnoses and procedure codes and clinical documentation.
- Operates PC and encoder software to find and select appropriate diagnosis and procedure codes.
- Operates fax machine in order to request and receive clinical documentation from external sources.
- Maintains and ensures a safe environment for the department. Handles and operates all necessary equipment and performs required duties according to established safety standards to maintain compliance with regulations and prevent injury.
PHYSICAL DEMANDS AND ENVIRONMENTAL CONDITIONS - Sedentary work - lifting 25-30 pounds occasionally or lifting and carrying 25-30 pounds occasionally.
- Indoor work - not exposed to outside elements or hazard.
- Near acuity and accommodation are required for reviewing the medical records and assigning ICD-10-CM codes.
- Reaching, handling, and fingering and/or feeling are required for keyboard and mouse entry.
- Requires sufficient sight to see and read reports and computer screen. Requires sufficient hearing and speaking to communicate by phone or in person.
QUALIFICATIONS (Education/training And/or Experience) EDUCATION - Required
Advanced education from an AHIMA or AAPC accredited program.
EXPERIENCE â?? Preferred
One year ICD-10-CM coding experience with inpatient or outpatient records.
CREDENTIAL â?? Required
For Inpatient: CCS, and/or RHIT (AHIMA), AAPC certification CIC with application work experience
For Outpatient: CCS, CCA or RHIT (AHIMA) or COC (AAPC)
SKILLS - Required Extensive knowledge of medical terminology, anatomy and physiology, disease pathology and coding principles. Attention to detail. Knowledge of Medicare and Medicaid regulations and resources. Must have excellent reading, grammar, and organizational skills.
Background checks are conducted. When specific authorization forms are requested so that full background and history can be obtained, employees/applicants must sign the form(s) requested.
Job Tags
Work experience placement, Immediate start,