Medical Records Coder I AdventHealth Daytona Beach
Location Address:301 Memorial Medical Parkway Daytona Beach, FL 32117
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You Will Be Responsible For:
Performs review functions associated with accurate code assignment on referral and recurring patient accounts.
Assigns diagnosis and procedure codes following ICD-10 Official Coding Guidelines for diagnoses and procedures, CMS, CPT, Coding Clinic guidelines, various other governing bodies and Department coding policies and procedures.
Interprets and reviews medical record documentation to assign accurate diagnoses and procedure codes for hospital referral accounts according to the supporting physician documentation in the record.
Assigns correct ASC/APC modifiers to ensure appropriate reimbursement and assigns the correct revenue code for all CPT codes when applicable.
Validates that all clinical tests performed meet medical necessity according to local and national policies.
Interacts with HIM employees and other departments to resolve issues and escalates problems to the appropriate level for resolution. Report any excessive or unusual write-offs to the appropriate level for further investigation.
Demonstrates knowledge of sequencing diagnoses and procedures as outlined in the Official Coding Guidelines, Uniform Hospital Discharge Data Set, CPT, and CMS guidelines.
Abstracts data in compliance with national, state, regional, and local policies which includes all of the following. Reviews assigned charges in the charge viewer to verify what is ordered and what procedures are carried out. Communicates to various departments when charges need to be added, deleted, or changed and when discharge dispositions and patient type/status needs clarified. Assigns proper modifiers when needed. Reviews the encounter for proper admission source, discharge disposition, and assigns the operative physician and date of procedure to the chart-coding screen.
Is proficient in navigating the electronic medical record and all supporting information management and billing systems. Must be proficient in the use of the encoder and computer assisted coding software application.
Demonstrate expert job knowledge and applies current coding and billing regulations, policies, processes, and procedures with effective decision-making and problem solving skills.
Meets and exceeds established coding and abstracting quality and productivity standards.
Participates in department performance improvement reviews and coding reviews. May provide training and support and or quality support as directed. Is flexible and willing to adapt to changes in the work environment.
Maintains the confidentiality of employees, patients, administrative staff and medical staff information at all times without any infraction.
Comprehensive knowledge of coding functions, rules, and guidelines.
Critical thinking and problem solving skills are essential along with the ability to work independently, remotely and with minimal supervision. Must be self-motivated and able to use electronic resources.
Remain informed and educated about changes in the reimbursement system and coding conventions and current updates.
What You Will Need:
KNOWLEDGE AND SKILLS REQUIRED:
Computer proficiency required.
ICD-10-CM Diagnoses, ICD 10 PCS and or CPT coding skills.
EDUCATION AND EXPERIENCE REQUIRED:
Requires two to four years in an HIM accredited program and/or successful completion of national certification exam.
Credentials as a RHIA, RHIT, CCS, or CPC.
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
Registered as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or high school graduate with certification as a Certified Coding Specialist (CCS) or Certified Professional Coder (CPC).
Performs a thorough review, assessment and analysis of the referral and recurring medical record documentation applying the appropriate ICD 10 diagnoses and procedures codes, CPT procedure codes and modifiers for billing and classification.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.