Medical Records Coding Technician abstracts clinical information from medical records and assigns the appropriate ICD or CPT codes using industry-standard coding guidelines. Assigns required DRG (diagnosis-related grouping) codes. Being a Medical Records Coding Technician works with coding databases and software to input and maintain data according to standard procedures. Performs quality audits of work. Additionally, Medical Records Coding Technician maintains and up-to-date knowledge of coding and documentation requirements. Requires a medical coding certification. The exact type of coding certification may vary based on the clinical setting or a medical specialty focus. May require an associate degree. The AAPC Certified Professional Coder (CPC) certification is typically required. The Certified Coding Specialist (CCS) certification is also a typical requirement. Typically reports to a supervisor or manager. The Medical Records Coding Technician works independently within established procedures associated with the specific job function. Has gained proficiency in multiple competencies relevant to the job. To be a Medical Records Coding Technician typically requires 3-5 years of related experience. (Copyright 2024 Salary.com)
Please note: All Duke medical coding opportunities require candidates to have a North Carolina address as a condition of employment.
FT Hospice/Home Health Coder position (Hybrid)
*Now offering a $5,000 commitment bonus that will pay out in 2 equal installments over 12 months in 6-month increments.
MAJOR JOB RESPONSIBILITIES
• Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions
• Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions.
• Sequence the diagnoses and procedures using coding guidelines. Ensure DRG (Diagnostic Related Grouping) /APC (Medicare’s Ambulatory Payment Classification) assignment is accurate.
• Abstract and compile data from medical records for appropriate optimal reimbursement for Home Health or Hospice and/or professional charges.
• Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.
• Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs
to effectively apply ICD-10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
• Maintain a thorough understanding of medical record practices, standards, regulations, The Joint Commission, Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), DHHS (Department of Health and Human Service), etc.
• Assist with special projects as required.
• Perform other related duties incidental to the work described herein.
PREFERRED QUALIFICATIONS
Education and Formal Training
High School Diploma required
Licensures, Certifications
Must hold one of the following active/current certifications:
Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding (Preferred)
Certified Professional Coder (CPC)
Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
Registered Health Information Administrator (RHIA) Hospital Coding
Registered Health Information Technician (RHIT) Hospital Coding
Professional Work Experience
Prior experience in homecare and hospice coding strongly preferred
RHIA certification- no experience required
RHIT certification- no experience required
CCS certification- one year of coding experience required
CPC or HCS-D certification- two years of coding experience required
Knowledge, Skills & Abilities
Advanced ICD-10-CM & CPT-4 coding conventions
Anatomy and Physiology
Medical Terminology
Extensive DRG/APC reimbursement knowledge
HH PDGM Knowledge R/T Coding
Coding software familiarity
Effective written and verbal communication skills
Data entry/CRT
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