Under moderate direction, reviews and interprets medical record documentation, assigns diagnostic and/or procedural codes, and abstracts case information for reimbursement, research and planning purposes. Ensures that all codes assigned are supported by sufficient documentation and are based on official coding and reporting guidelines. Interacts with medical staff, clinical documentation improvement specialists, and other hospital departments to improve the quality of documentation, and ensures documentation accurately reflects the severity of illness and intensity of service for each patient.
1. Reviews medical record documentation to identify pertinent diagnosis/procedures that require code assignment for inpatient/outpatient records and accurately code the diagnoses and procedures using ICD-10 and/or CPT coding conventions for the purpose of reimbursement, research, and compliance with federal regulations.
2. Reviews the medical record to assure specificity of diagnoses, procedures, and appropriate reimbursement for hospital and professional charges.
3. Queries physicians, with the support of the Clinical Documentation Improvements Specialists, when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
4. Keeps abreast of coding guidelines and reimbursement reporting guidelines and brings identified concerns to manager for resolution.
5. Effectively assigns ICD-10-CM, ICD-10-PCS, CPT codes, DRG and/or APC to record accounts.
6. Responsible in maintaining 95% in ICD-10-CM, ICD-10PCS, CPT and DRG assignment and consistently meet established productivity standards while keeping abstracting errors to a minimum.
7. Abides by the Standards of Ethical Coding as set for the by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
8. Adheres to all Beaumont Health System policies, procedures, and standards within budgetary specifications including time management, remote teleworking, and productivity and quality of service.
9. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education to maintain certification and skills competency; supports department-based goals which contribute to the success of the organization and the Health Information Management department; may serve as a preceptor (students internships).
10. Other duties as assigned.
This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.
1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.
2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.
3. Supports and adheres to all Beaumont Health’s customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.
4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.
5. Supports and participates in a collaborative team-oriented environment – cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.
6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules – including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.
7. Completes all required compliance standards that may be department specific and/or identified by the organization.
8. Maintains current licensure, registration and/or certification, as applicable, at all times.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
A. Education / Training:
· Associate or bachelor’s degree in health information management, required.
B. Work Experience:
· ICD-10-CM/ ICD-10-PCS, CPT coding experience, preferred.
C. Certification, Licensure, Registration:
· Registered Health Information Technician (RHIT) or Registered Health Information Associate (RHIA), preferred. Must obtain RHIT, RHIA credentials within 6 months of employment.
D. Other Qualifications:
· Knowledge of human anatomy, physiology, pharmacology, and medical terminology. Effective oral and written communication skills. Computer and EHR skills and excellent ability to concentrate.
* Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.