Participates daily, in coding and abstracting activities. Identifies, reviews, interprets, abstracts and codes clinical information from Inpatient records with some back up in area of outpatient surgeries and observation records for the purpose of research, reimbursement and compliance with federal regulations and other agencies utilizing established coding principles and protocols. Meets productivity and quality standards and must meet coding/abstracting goals to expedite the billing process, as well as, expedite the retrieval for physician access and ongoing patient care.
Identifies, reviews, interprets, codes and abstracts clinical information from the medical record for the purpose of reimbursement, research and compliance with federal regulations and other agencies using established coding principles and protocols.
Identifies and codes Inpatient records for the purpose of reimbursement, research, and compliance with federal regulations according to diagnosis and procedure using 1CD-9-CM and CPT-4 coding systems.
Serves as back up coder for outpatient surgery, observations and diagnostics, as necessary.
Applies ICD-9-CM and CPT 4 coding system guidelines.
Interprets clinical data and applies Uniform Hospital Discharge Data Set definitions to identify the diagnostic and procedure codes.
Abstracts pertinent information from clinical notes, operative records, radiology reports, pathology, specialty forms, etc. Interprets diagnostic workups, surgical techniques, advanced technology and special services, identifies medical and surgical complications and untoward events and enters into the abstracting computer system.
Serves as back up to Coder 2 or Coder 1 by training in and the coding of outpatient surgeries, observations, ED or diagnostic cases as required.
Reports discrepancies to the HIM Supervisor or Director when final abstract is unable to be sent due to physician related issues or lack of proper documentation.
May contact physician and/or ancillary departments, clarifying information with DRG Assurance staff when additional information is needed to accurately code the record.
Strives to decrease pending accounts on all assigned patient types as assigned.
Assures accuracy and timeliness of code assignments required to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
Assists in and participates in quality improvements activities of the HIM Department as assigned.
Supports special studies in relation to coding and abstracting information, as assigned.
Performs follow up coding of medical records as a result of internal or external reviews which identify coding, DRG or APC discrepancies.
Conducts selection/sequencing of principal and secondary diagnosis/principal procedures and secondary procedures done correctly at least 95% of the time.
Abstracts correctly all appropriate data elements at minimum 95% of the time.
Maintains knowledge and skills through a variety of methods including reading current coding resources, clinical information, in-services, etc.
Attends and participates in coding education sessions.
Meets and exceeds minimum standard productivity requirements outlined in departmental coding benchmarks.
Promotes good morale and cooperation to enhance the coding and/or HIM team.
Maintains good working relationship with DRG Coordinators to facilitate accurate and complete coding.
Maintains flexibility to meet organizational demands for new skills and knowledge.
Meets coding deadlines to expedite the billing process and to facilitate data retrieval for physician and on-going care.
Other duties as assigned.
Graduation from accredited Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) program or Certified Coding Specialist (CCS) certified or two years of college education in science related field including anatomy/physiology, basic disease process, medical terminology.
Requires strong verbal skills in interpersonal situations.
Complexity of Work:
All employees are expected to meet the standards of performance outlined in the Organizational-Wide Competencies listed below as applied to the position: World Class Service Orientation: Includes attitude, behavior, interpersonal skill, and problem solving that enable an employee to respond to internal and external customer needs and expectations in a positive manner.
Adaptability: Includes teamwork and flexibility needed to fulfill job responsibilities including adapting to changes in work environment and accepting supervisory feedback.
Efficiency and Effectiveness: Includes quantity and quality of desired work, as well as organization skills necessary to perform successfully.
Essential Job Requirements:
Includes adherence to all relevant policies, procedures, and guidelines affecting the work environment, including maintenance of required competencies and communication skills.
Supervisory Responsibilities (if applicable): Includes overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
Minimum of 2 or more years experience in the application of ICD-9-CM and CPT-4 coding, recording of and interpreting clinical data from medical records of inpatients in acute care facility.
After selection and placement into this position, at least 3 months of on-the-job training with attendance at comprehensive training sessions in order to code clinical data with a high degree of accuracy.
This position requires a large amount of physical work including lifting of a maximum 20 pounds, carrying and filing of medical records and documents weighing up to 20 pounds.
Filing records requires reaching, pulling, pushing, bending and stooping.
Mental Demands: Ability to work at a fast pace and to prioritize multiple assignments/projects and respond to numerous requests; ability to work collaboratively with department director(s); physicians, and other members of the Healthcare team, ability to ensure operational efficiency; ability to exercise self control and tolerate stress when dealing with multiple requests and/or conflicting demands from multiple customers.
Special Demands ; Needs minimal, direction in assessing needs, self starting and self motivating; working hours may exceed eight (8) per day and is based on what is needed to accomplish work at hand.
Confidentiality: This position has access to the entire medical record for the purpose of quality Healthcare.
In addition, in this position the employee will limit the PHI disclosed or requested to the amount reasonable necessary to achieve the purpose of the request.
The disclosure or requests that occur on a routine or recurring basis include demographic information.
The employee makes these disclosures for the purpose of compliance.
Criteria established to limit the PHI disclosures/requests to that which is reasonable necessary includes general information.
Personal Protective Equipment:
The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic's Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.
Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities