Job Summary
Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior.
Codes and abstracts inpatient medical records of all types and, following a rigorous review of the clinical documentation, abstracts and assigns appropriate ICD-10-CM/PCS code sets and assigns the correct APR-DRG into the hospital information system. May also code other work types as assigned by the Coding Manager.
Essential Functions:
· Determines the correct principal diagnosis, identifies and assigns co-morbidities and complications, secondary diagnoses, present on admission indicators for ICD-10-CM and MHACs (Maryland Hospital Acquired conditions), principal procedure codes and secondary procedure codes.
- Assigns the appropriate APR-DRG.
- Works in collaboration with CDI to ensure that the MHACS (Maryland Hospital Acquired Conditions) and PQIs (Prevention Quality Indicators) are correctly assigned.
- Identifies and correctly codes and sequences ICD-10- CM/PCS diagnoses and procedure codes for appropriate optimal reimbursement.
- Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.
- Protects confidential medical information following HIPAA guidelines.
- Accurately abstracts the Attending Physician, Discharge Disposition and location Discharged to, Consultations, Ambulance Run Number & County codes, Date (s) of surgery or other procedures, Cause of Death if applicable, and Anesthesiologist.
- Writes compliant Queries to the physician when documentation is not clear or incomplete.
- Participates in an Abstract Peer Review to ensure that the abstract elements are correct
- Works in collaboration with other departments including Registration, Patient Financial Services, Lab, Pathology and Medical Records.
- Participates in Special Projects to include the Aging Report or review of denials.
- Meets Productivity Standards on a daily basis. (See Coding Productivity Standards)
- Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participating in continuing education programs to effectively apply ICD-10-CM and CPT coding guidelines to inpatient and outpatient diagnoses and procedures.
- Identifies the correct location in the medical record to obtain pertinent information such as (i.e. BMI, Hemodialysis, Blood Transfusion, Pressure Ulcers, Isolation, Mechanical Ventilation and orders.
- Keeps up-to-date on the HSCRC guidelines and state and national specific coding updates and guidelines.
- Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO) and HSCRC (Health Services and Cost Review Commission).
Required Knowledge, Skills and Abilities:
- PC experience; ability to use computer terminals for prolonged periods to enter data.
- Ability to work under time and productivity constraints.
- Ability to work with frequent distractions/interruptions.
- Ability to read records and handwriting of differing levels of legibility for prolonged periods.
- Attention to detail.
- Good organizational skills.
- Ability to sit for prolonged periods.
- Ability to reach, bend, lift, and carry medical records.
- Good public relations and communication skills.
- Good judgment when dealing with others.
Minimum Education, Training, and Experience Required:
- High School Diploma or GED required. Completion of a Coding Certificate Program is required.
- At least one of the following: CCS (Certified Coding Specialist), RHIA or RHIT credential is required
- 5 to 10 years’ hospital coding experience which includes coding of inpatient records or a combination of inpatient and outpatient records using both ICD-10-CM and CPT is preferred. Demonstration of skills through completion of a hospital administered advanced coding test with a satisfactory score.
Caring for you as you care for the CommUNITY
Frederick Health offers a comprehensive and affordable benefits package. Health, Dental and Vision insurance are offered the 1st of the month after 30 days of employment to all employees hired to work at least 20 hours per week and we offer multiple plans to best meet your and your family's needs. Life insurance, Short-Term Income Replacement and Long-Term Disability are employer paid for eligible employees. Frederick Health offers a robust Paid Time Off program for eligible employees. Our 403B retirement plan helps you save for your retirement and includes an employer match to eligible employees. All employees have access to free financial planning sessions. We also offer an educational assistance program to support your education goals as well as an employer paid Employee Assistance Program.
Pay is based on experience, skills and education. If position is part-time, salary will be pro-rated based on scheduled hours. The pay range may also vary within the stated range based on specialty if applicable. Non-Exempt positions may have shift differential and/or Overtime paid, if applicable.
Hourly pay range: $26.46-$37.80
Hours: Monday-Friday, 8:00am-4:30pm or flexible
Preferred
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5 - 10 years: Hospital coding experience which includes coding of inpatient records or a combination of inpatient and outpatient records using both ICD-10-CM and CPT is preferred.
Required
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Certification or better
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High School or better
Required
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
