Responsible for the timely and accurate assignment of diagnosis and procedure codes through the utilization of the ICD-9-CM and CPT-4 classification systems. Perform coding of all Medicare (primary and secondary payor), PPS (rehab), and Behavioral Medicine and other inpatient coding. May also be responsible for performing Interventional Radiology, Cath Lab, or other outpatient surgery coding. Communicate with the CDS's while the patient is still in-house to obtain complete documentation in the record for accurate and complete coding. Assist in Quality Improvement activities and act as resource for Medical Record Department coding personnel.
- Concurrently review all Medicare (primary and secondary payor) admissions in 24 to 48 hours of admission. Assign ICD-9-CM codes to the in-house chart with a 94% accuracy level, as determined by random audit. Communicate with the attending physician/CDS's to obtain complete documentation of the case to ensure optimal coding with follow-up and self audits.
- Code abstract diagnoses and procedures according to accepted ICD-9-CM coding guidelines, HCFA/Medicare regulations and hospital standards for all Inpatient (Medicare may be coded concurrently or retrospectively), Outpatient Surgery, Interventional Radiology, Emergency Room, Private Referral outpatient, Observation and outpatient patients. Code procedures according to CPT-4 guidelines for all Medicare outpatient and emergency room records. Communicate with physicians and clinicians/CDS's concerning diagnoses and procedures when coding questions arise. Maintain an accuracy rate of 94% on random audit. The productivity standards are: 3.8 records coded/hour for in-patient, private pay, Medicare, or commercial; 5 records/hour for outpatient surgery records; 6 records/hour for emergency room; 90% of all records are coded within four (4) days of discharge.
- Ensure optimum reimbursement through accurate coding and DRG assignment. Maintain an accuracy level of 93% in DRG assignment as determined in random audits.
- Extract clinical and demographic information from medical records in accordance with established standards for the hospital's internal computerized clinical abstract database. Abstract all Inpatient, Outpatient Surgery, Interventional Radiology, Emergency Room, and outpatient records within four days of discharge with an accuracy level of 94% as determined by random audit. Utilize the computer terminal for data input/output and for the release of coded data as required on the UB-82 bill (drops bills). Ensure all records are sent accurately and timely.
- Respond appropriately to requests for coding information from physicians, Business Office, and others. Generate routine and customized reports as needed/requested.
- Stay abreast of all changes in coding conventions and coding updates by reading in-service materials provided by professional organizations.
- Act as resource for other Coding Technicians and assist in assigning codes for complex medical records.
- Perform other related duties as directed that correspond to the overall function of this position.
Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred. RHIA, RHIT or CCS may be substituted for experience.
Two years of current in-patient coding experience.
Extensive knowledge of ICD-9-CM and CPT coding methodologies.
St. Anthony Hospital –
St. Anthony Hospital is a 601-bed regional referral facility specializing in cardiology, oncology, surgery and behavioral medicine. The hospital, established in 1898, is located in Midtown Oklahoma City and serves the needs of Central Oklahoma, as well as many counties throughout Oklahoma, through its large rural affiliate network of hospitals. Four St. Anthony Healthplex campuses provide convenient emergency and outpatient service access to the outlying communities of the metropolitan area. St. Anthony added urgent care services in May 2015 at St. Anthony North. St. Anthony has received numerous awards including the Oklahoma Quality Award for Excellence, Certified Healthy Business, Premier QUEST® Award for High-value Healthcare Citation of Merit, among others. Healthsights ranks St. Anthony at performance levels for quality and patient satisfaction higher than local competitors and many national health care organizations.