Overview
Individual responsible for coding all hospital records for purposes of reimbursement, research, and compliance with federal regulations. Applies correct ICD-10-CM diagnosis, ICD-10-PCS or CPT procedure codes, applies modifiers and assigns appropriate DRG, APC, and E-APG’s. Coder must abstract statistical data from records into hospital abstracting system in accordance with hospital policies and procedures. Individual must have knowledge of ICD-10-CM/PCS, CPT, APC’s, E-APG’s, and DRGs, federal and state coding guidelines.
Responsibilities
Reviews patient’s entire current medical record and assigns appropriate ICD-10-CM diagnosis, ICD-10-PCS or CPT procedure codes according to accepted coding guidelines and hospital’s policies and procedures. Assigns accurate DRG, APC, or E-APG to patient’s record utilizing hospital encoding system. Accurately abstracts statistical data from records using hospital abstracting system in accordance with hospital policies and procedures. Corrects any edits flagged by encoder and financial system. Understands and applies modifiers appropriately. Attends hospital sponsored educational programs and department coding meetings. Participates in and practices lean management principles and processes. Â
DCH Standards:
- Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
- Performs compliance requirements as outlined in the Employee Handbook.
- Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
- Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
- Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
- Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
- Requires use of electronic mail, time and attendance software, learning management software and intranet.
- Must adhere to all DCH Health System policies and procedures.
- All other duties as assigned.
Qualifications
Graduate of an AHIMA accredited medical coding program. Must pass DCH’s coding proficiency assessment for coders. RHIA, RHIT, CCS preferred. Medical terminology knowledge, anatomy & physiology coursework required. Some computer or computerized encoder experience. Ability to maintain confidentiality absolutely required. Must be able to read, write legibly, speak, and comprehend English. WORK CONTEXT
Requires the ability to work 8 hours quietly at a computer screen and keyboard/mouse. Must be able to meet deadlines as assigned. Requires the ability to withstand pressures of constant deadlines, audits, educational demands and changing healthcare environment. Must have ability to accept criticism and to deal calmly and effectively in high stress situations.  Must be able to communicate both verbally and in writing on a daily basis. Must be able to participate in groups. . Must be able to adapt to changes in work area as assigned. Displays a willingness to take on responsibilities and challenges. Ability to maintain confidentiality. PHYSICAL FACTORS
Hearing and vision must be normal or corrected to within normal range. Able to perform the duties with or without reasonable accommodation. This job is considered light work. Must be able to exert up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. This job involves standing, walking, sitting, stooping, pushing, pulling, and crouching. Ability to lift up to 20 pounds occasionally and 10 pounds frequently. Must have good dexterity Should be able to reach and extend arms in any direction.
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