Hospital Coder - Medical Records (Full Time)
Uvalde Memorial Hospital
- Uvalde, TX
- Permanent
- Full-time
- Ensures that records are coded within the current UMH deadline (i.e. 4 days of discharge, excluding weekends and holidays).
- Reviews chart thoroughly to ascertain all diagnoses/procedures.
- Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on chart.
- Ensures coded diagnosis and procedures on clinical summary agree with physician.
- Refers chart to director, if there is a question regarding the diagnoses/codes.
- Utilizes computerized coding/abstracting equipment.
- Codes all diagnoses/procedures in accordance to ICD-10-CM and CPT-4 coding principles and the Coding Manual.
- Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.
- Reviews coding periodicals within 7 days of receipt.
- Notifies director whenever work is more than 48 hours behind work deadline.
- Assists the director with state requirements and reports.
- Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
- Acts as a resource person to hospital staff for coding and may provide education regarding coding changes/issues.
- Must be familiar with all charting and coding requirements, coding guidelines and coding clinics.
- Performs concurrent coding for Clinical Documentation Improvement (CDI) (for inpatient coder only)
- Review query logs.
- Work up and enter CRNA charges.
- Willing to accept additional assignments.