Summary of Essential Functions

• Processes, reviews, abstracts, codes and indexes diseases, operations, treatments and computes observation time charges on outpatient medical records, ensuring governmental compliance on regulatory issues

Educational Requirements

• High School Diploma or equivalent.
• Must be able to communicate effectively in English, both verbally and in writing.

Knowledge/Skills/Abilities

• Minimum of one year experience outpatient coding in an acute health care setting.
• CCS preferred.
• Ability to interpret medical record, concentrate and maintain accuracy in spite of interruptions, initiative, to use standard office equipment and to maintain confidentiality with regard to aspects of work.
• Knowledge of medical terminology, anatomy, coding/classification systems, reimbursement principles, and coding software preferred.
• Organizational skills and good communication skills to assist physicians in questions regarding documentation of diagnostic entries, according to Joint Comission/HCFA and hospital guidelines.

Physical Requirements

• Vision acuity, hearing sensitivity and manual dexterity.
• Occasional bending, stooping, kneeling, reaching, lifting and standing.

Duties and Responsibilities

• Reviews and codes all diagnoses according to ICD-9-CM coding classification systems and regulatory guidelines. Maintaining a 95% or higher quality rating.
• Reviews and codes all procedures according to ICD-9-CM coding classification systems and regulatory guidelines. Maintaining a 95% or higher quality rating.
• Reviews and codes all procedures according to CPT-4 coding classification systems and regulatory guidelines. Maintaining a 95% or higher quality rating.
• Demonstrates a consistent level of performance; strives to maintain a minimum productivity of 15 charts per hour.
• Abstracts and indexes medical records, according to governmental compliance and hospital guidelines.
• Verifies and processes Medicare 72 hour messages to ensure proper account handling.
• Supports and participates in meeting departmental goals.
• Displays professionalism and courtesy in assisting physicians and other departments in problem solving.
• Reviews outpatient records, computes observation time and posts the charges to the patient account.
• Performs all other tasks/responsibilities as necessary.