Under direction, is responsible for the review of inpatient, outpatient and emergency department medical record information and converting diagnosis and treatment procedures into codes for abstracting medical information; and does related or other work as required in accordance with Rule 3, Section 3, of the Civil Service Rules.
CLASS CHARACTERISTICS
An incumbent in this class is either a Certified Coding Specialist (CCS) with the American Health Information Management Association or Certified Professional Coder (CPC) with American Academy of Professional Coders and performs the most complex coding and abstracting of inpatient, outpatient, and emergency department medical record entries according to the most current edition of International Classification of Diseases Clinical Modification System (ICD-9-CM) and Current Procedural Terminology (CPT-4).
TYPICAL DUTIES
Completes detailed analysis of medical records for chart content and documentation requirements.
Assigns diagnostic codes and abstracts patient medical record information according to the International Classification of Diseases 9th Edition Systems (ICD-9-CM) and Current Procedure Terminology (CPT-4) Manual and coding conventions and guidelines as established by state and federal reporting requirements.
Completes abstracting functions of inpatient, outpatient, and emergency records.
Enters coded medical records data on computer terminal; selects diagnosis and operations codes from computer encoder and designated abstracting system.
Review medical records and verifies coding and Medicare Severity Diagnosis-Related Groups (MS-DRGs) assignments in response to billing requests.
Responds to authorized request from agencies, administration and individuals regarding coding and DRG questions.
Maintains a working knowledge of current guidelines and regulations affecting code assignments through continuing education sessions and approved references.
Assists physicians with correspondence for legal and insurance information.
Keep records and prepares reports and correspondence as required.
May serve as a lead worker; may train staff.
MINIMUM QUALIFICATIONS
Experience: One year of experience in an acute-care hospital or health care facility with experience in medical coding or medical records.
Certification: Possession of a current Certified Coding Specialist (CCS) certificate issued by the American Health Information Management Association or Certified Professional Coder (CPC) certificate issued by the American Academy of Professional Coders.
Substitution: Current registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) certificate may be substituted for the CCS or CPC certificate.
KNOWLEDGE
Medical terminology, anatomy and physiology, and study of disease processes; current knowledge of abstracting medical records according to ICD-9-CM classification systems and CPT-4 coding guidelines; standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; health information systems for computer application to medical records.
ABILITY
Review medical record information, correctly assign codes to diagnosis and procedures; utilize the ICD-9-CM and CPT-4 coding guidelines to code medical record entries; abstract information from medical records in accordance with defined regulations; read medical record notes and reports; assign accurate Medicare Severity Diagnostic Related Groups; operate computers, office equipment and related software; make independent decisions in procedural matters; establish and maintain effective working relationships with other employees, physicians, and the general public; communicate effectively, both orally and in writing.
PHYSICAL/MENTAL REQUIREMENTS
Mobility-Frequent operation of a data entry device, repetitive motion, sitting and standing for long periods, walking; occasional pushing, pulling, bending, stooping, squatting, climbing; Lifting-Frequently 5 pounds or less; occasionally 5 to 30 pounds; Visual-Constant good overall vision and reading/close-up work; frequent color perception and use of eye/hand coordination; occasional use of depth perception and peripheral vision; Hearing/Talking-Frequent hearing of normal speech, hearing/talking on the telephone, talking in person; Emotional/Psychological-Decision making; concentration; occasional exposure to trauma, grief and death; Special Requirements-Some assignments may require working weekends, nights, and/or occasional overtime; Environmental-Occasional exposure to varied weather conditions.
San Joaquin County complies with the Americans with Disabilities Act (ADA) and, upon request, will consider reasonable accommodations to enable individuals with disabilities to perform essential job functions.
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