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- Applies the appropriate coding guidelines for assignment of the primary diagnosis and co-morbidities for outpatient accounts.
- Applies the appropriate guidelines for assignment of primary and secondary procedures.
- Assigns the appropriate ICD-10-CM code for the primary diagnosis on 95% of accounts audited.
- Assigns the appropriate CPT codes for procedures on 95% of accounts audited.
- Assigns the appropriate Evaluation & Management code on 95% of accounts audited.
- Abstracts required demographic and statistical data from each patient record on 95% of accounts audited.
- Demonstrates knowledge of the content of the electronic medical record for both inpatient and outpatient accounts.
- Demonstrates knowledge of the physician query process and appropriately queries when documentation is incomplete or ambiguous.
- Demonstrates appropriate analysis of electronic medical record documentation for completeness, accuracy, and timeliness.
- Maintains an average productivity rate of 130 accounts coded per day.
- Identifies both electronic and hard copy reference materials appropriately and efficiently to facilitate the accuracy, consistency and specificity of code assignment.
- Coordinates with the Clinical Coding Support Specialist on issues related to documentation.
- Maintains confidentiality of patient’s protected health information (PHI) in both electronic and paper formats.
- Participates in continuing education programs and maintains a record of continuing education programs attended.
- Performs other duties and participates in special projects as assigned by the HIMS Management team.
Experience in a Health Information Management (HIMS) Department or Medical Records Department preferred.
- Experience utilizing health information systems (HIS) software or equivalent experience preferred.
- Familiarity with a coding and abstracting system preferred.
- Good verbal and written English language skills.