SCRMC Medical Records Coder (DRG)

JOB SUMMARY

To abstract and code ICD-9-CM required by CPHA Type II abstracts from each dismissed patient's medical record, according to CPHA procedures and standards and the needs of the Medical Records Department, the administration, medical staff, etc.

JOB REQUIREMENTS

Minimum EducationHigh school diploma or equivalent.

ART, RRA, or medical records training.

Training as coder abstractor.

Minimum Work ExperienceFive years of acute care hospital coding required.

Two years of experience in inpatient coding.

Two years demonstrated knowledge of medical terminology.

Required SkillsHighly organized.

High attention to detail and accuracy.

FUNCTIONAL DEMANDS

Understanding of ICD-9-CM and CPT-4.

Thorough knowledge of classification and nomenclature, anatomy, medical terminology, and medical records procedures and practices.

Work is sedentary in nature; however, the ability to stand and/or walk for periods of three hours or more and examine or manipulate objects at high or low reach is required. The position requires some pulling, filing, and copying of charts.

Work is repetitive and monotonous in nature and requires concentration and constant technical attention to accuracy and detail for extended periods of time.

ORGANIZATIONAL EXPECTATIONS

Provides a positive and professional representation of the organization.

Promotes culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.

Maintains hospital standards for a clean and quiet patient environment to maintain a positive patient care experience.

Maintains competency and knowledge of current standards of practice, trends, and developments in related scope of job role or practice.

Adheres to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.

Participates in ongoing quality improvement activities.

Maintains compliance with organization’s policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards.

Complies with organizational and regulatory policies for handling confidential patient information.

Demonstrates excellent customer service through his/her attitude and actions, consistent with the standards contained in the Vision, Mission, and Values of the organization.

Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements, and TJC standards and/or standards from other accrediting bodies.

ESSENTIAL FUNCTIONS

Abstracts in detail and completes case abstract from the patient's medical records.

Codes (ICD-9-CM or CPT-4) each patient record for indexing operations, diagnoses, and physicians' and surgeons' planning reports, etc.

Organizes work for accuracy and effectiveness of reporting system.

Audits monthly reports for correctness to ensure accuracy of semiannual and annual reports and indexes.

Reports to the infection control officer all possible nosocomial infections identified at the time of coding and abstracting.

Reports to the quality assurance coordinator any unusual occurrence not accompanied by a report from the nursing department.

Identifies cases for tissue review at the time of coding and abstracting and prepares the monthly tissue review worksheet for the surgery committee.

Abstract and enters records as they are completed and/or by deadline dates established by the director.

Performs daily, monthly, and yearly departmental statistical review.

Reports coding problems to the medical records assistant director after evaluation and/or coding, using the consulting service of the CHPA.

Attends training sessions as requested and/or desired for knowledge or expertise.

Gives advice on the selection of optional areas for new abstract items desired. Reports deficiencies found during chart reviews and abstracting.

Reviews and aids with the monthly reporting system and in special studies or audits for committees, etc. Sets up the report format on Meditech for monthly abstracting statistics.

Assembles and checks charts for deficiencies when designated. Rechecks charts after physicians complete them.

Maintains an ongoing surveillance of the abbreviations in use and submits new abbreviations to the medical records director for possible approval.

Trains employees for backup when requested.

Performs other similar and related duties as assigned.