Job Summary: This position is responsible for the assignment of ICD-10-CM diagnosis and procedure codes and as appropriate, CPT-4.
Reviews the complete electronic and paper medical record of discharged patients. Assigns ICD-10-CM diagnosis and procedure codes from documentation in the medical record, when indicated assigns CPT-4 procedure codes.
Abstracts coded data and patient information into the coding abstracting system in use by BIDMC (information includes attending physician, surgeon, dates of surgery, disposition, discharge date, and infant birth weight etc.). Uses the AHA 'Coding Clinic for ICD-10-CM' for official coding guidelines set forth by the ICD-10-CM Coordination and Maintenance Committee.
Sequences the assigned codes, exercising all principles of assigning ICD-10-CM codes to determine the appropriate selection. Prioritizes daily work to ensure timely submission to the billing system.
Participates in training programs including educational sessions for updates to ICD-10-CM, Coding Clinic Guidelines and learning ICD-10-CM/PCS.
Follows Policy & Procedure to identify and facilitate prompt resolution of documentation, abstracting and/or other account problems.
High School diploma or GED required.
1-3 years related work experience required in coding or coding credential of Certified Professional Coder, RHIT, CCS, or CCS-P.
Knowledge of anatomy, physiology, medical terminology, disease processes, pharmacology and the ICD-10-CM, CPT-4 coding systems.
Two years coding experience in ICD-10-CM and CPT-4 coding systems.
Basic familiarity with computers. Ability to navigate at a basic level within web-based applications.
Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.
Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.
Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.
Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.
Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations.
Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.
Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.
Physical Nature of the Job:
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally
Beth Israel Deaconess Medical Center