JOB SUMMARY: Following established conventions and guidelines, codes and abstracts the medical records of inpatients. Groups codes to determine diagnosis related groupings (DRGs - CMS and/or APR). Primarily handling non-trauma but still very complex IP records. May also be asked to code day surgery, emergency and outpatient records. Meets departmental accuracy and production standards of 2 charts per day with 98% accuracy.

RESPONSIBILITIES:
CODES - Reviews medical records to determine the physician’s diagnosis/procedures for the patient and assigns ICD-10CM/PCS codes to those diagnoses/procedures.
Tasks:
• Reviews the entire medical record for codeable information.
• Writes queries as appropriate and adheres to the query policy. Follows-up on queries and updates coding and the query as appropriate and in a timely manner.
• Assigns the appropriate APR/DRG.
• Is familiar with and follows the Coding Compliance plan.

ABSTRACTS - Abstracts predetermined information from inpatient, day surg, ER, and outpatient records and enters that information on to the medical record abstract.
Tasks:
• Enters appropriate information on the abstract as determined by departmental policy.
• Completes and releases to billing abstracts that are ready to be billed.

COMMUNICATES - Assures that co-workers and management are well informed and adequately prepared by communicating information relevant to the coding area or department.
Tasks:
• Prepares and submits a properly completed management report to the Manager weekly.
• Notifies the Manager and/or Coordinator of charts with missing documents. Notifies admitting of registration errors.
• Works with Clinical Documentation Specialists to develop a good working team.
• Communicates about queries and query responses. Uses CDI as a resource for clinical information.
• Participates in department meetings, inservice, and peer interviews (as requested). Assists with the training of new employees and students as requested.
• Ensures that emails, audits, queries and reports are processed timely.

RESEARCHES - Researches to ensure that records are coded, grouped and abstracted properly.
Tasks:
• Contacts other departments to obtain information needed for coding such as diagnoses, procedures, treatments rendered, etc.
• Contacts physicians to obtain information (diagnoses, procedures, treatments, clarifications) needed for coding.
• Utilizes references (dictionaries, Coding Clinics, CPT assistant, Coding Policies, other literature, Clinical Documentation Specialists, Coordinator, Internal Auditor, etc) to help determine appropriate codes.

MINIMUM REQUIREMENTS:
• Formal working knowledge equivalent to an Associate's degree (2 years college) in HIM, HIT or related field
• 3-5 years of relevant coding experience
• CCS with 5+ years’ experience or RHIT, or RHIA required.
• Must complete 2 charts per day with 98% accuracy
• Ortho coding experience preferred