ED Coder / Certified

Job Description

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records. Logs all discharges into the computerized Discharge Log, enters specific data elements and verifies the discharge physician for all coded records. Serves as an onsite resource for both inpatient and outpatient coding issues. Maintains an understanding of both Inpatient and Outpatient Prospective Payment Systems.

Job Responsibility

• Assigns codes accurately to each record for diagnoses and procedures performed according to ICD-9-CM and CPT-4 coding and classification systems
• (This includes assignment of "modifiers" on required cases).Utilizes resources needed to adhere to coding guidelines (e.g
• Coding Clinic, Coding Handbook, etc.)
• Also uses reference materials (medical dictionary, Physicians Desk Reference, approved abbreviations) to ensure accuracy to align with Coding Compliance Regulations (Department of Justice / OIG).Abstracts data from the medical record and enters data directly into the 3M Application software
• (Utilizes data sheet only when needed during downtime)
• Responds correctly to prompts for refining of codes as well as tracking case managed patients, readmission status, discharge disposition, birth weight, O.R
• minutes, lesion size, type of anesthesia and ASA classification..Obtains corresponding pathology reports to ensure accurate coding to support documentation within the record
• Works in concert with DRG Validator on "DRG Assurance"
• Verifies proposed DRG to ensure accurate assignment for direct relationship to finance and reimbursement.Meets the required productivity and competency levels established for a full time Inpatient Coder
• (Inpatient : 20 ) Meets productivity and competency standards for coding of Ambulatory Surgical records for a full time employee.(Outpatient : 36) Codes pre-admission surgical testing forms on assigned day.Codes and enters discharges / re-admits at time of receipt from transferring unit.Completes DOH forms for appropriate records, i.e
• Spontaneous Termination of Pregnancy, Alzheimer's, Congenital Malformation, Induced Termination of Pregnancy, and Sterilization.Responsible for submitting DOH forms to the responsible person in a timely manner to ensure DOH Regulations are met
• Keeps a log of all forms sent.Assists in data audits as requested

Responds to suggestions for change in timely manner.Assigns charts to appropriate review area for coding validation check.Responds to physician's coding questions when necessary.Performs related duties as required.