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Under general supervision, assigns diagnostic and procedural codes to patient charts of moderate to high complexity levels using ICD-9-CM and CPT, HCPCS and any other designated coding classification system in accordance with coding rules and regulations.

Essential Functions

Reviews medical records for the determination and accurate assignment of all documented diagnoses and procedures.

Assigns and sequence codes based on medical record documentation.

Assigns appropriate discharge disposition.

Abstracts and enters coded data and designated quality management data for hospital statistical and reporting requirements.

Communicates documentation improvement opportunities and coding issues (i.e., discrepancies, physician queries, etc.) to the appropriate personnel for follow up and resolution.

Requirements

Registered Health Information Technician (RHIT), or

Registered Health Information Administrator (RHIA), or

Certified Coding Specialist (CCS) or Certified Coding Specialist – Payer (CCS-P), and

Minimum one year technical coding experience that includes all types of inpatient and/or outpatient cases

Experience in computerized encoding and abstracting in a Windows-based environment preferred

Strong analytical skills necessary to choose appropriate codes for moderate to complex cases while ensuring optimal hospital reimbursement, and to assist with the review of clinical information as requested.

Interpersonal communication skills to function as a coding resource to internal and external customers, function as a resource to entry-level coders, and interact with physicians regarding medical record information

Must protect and maintain the confidentiality of patient information and handle with discretion and integrity.