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)
Job Overview: This position strategies and supervises coding and abstracting processes to ensure timely and accurate coding and abstracting of inpatient and outpatient medical records assuring appropriate reimbursement via compliance with CMS regulations, standard coding conventions, and internal customer expectations. Performs coding, billing, and compliance audits as necessary. Job Requirements: Associate's Degree in Health Information Technology; Equivalent experience accepted in lieu of degree RHIT or CCS Proficiency in ICD and CPT coding, DRG’s, MSDRG’s, POA indicators Post-acute transfer rules -disposition status Disease process and treatment Anatomy and medical terminology Clinical documentation requirements 2-3 years of experience coding experience with both ICD and CPT Job Responsibilities: Trains and advises coding/abstracting staff on the correct use of codes and the use of the coding and abstracting system. Serves as back up to on-site Manager Interviews, hires, trains, evaulates, and coaches employees Supervises day to day coding and abstracting activities -schedules, staffing, resources, and workload priorities- to ensure that established standards and deadlines are met, coding as needed or as time permits. Coding Turnaround meets: 3-4 days below: Adds value as a member and consultant to organizational teams affected by coding compliance, including but not limited to,: RAC, Compliance, ALJ Committee, CDM Committee, Dual Coding and ICD-10 Education Workgroup, Managed Care Contracting, CDMP Task Forc Assures the quality of coded and abstracted data through continuous quality monitoring and facilitates multiple coding audits, defending hospital coding to multiple auditors, payors, agencies, and governmental authorities. Acts as a resource person to other hospital departments and external customers regarding coding questions and issues. Other Job-Related Information: Direct Report FTEs = 30-39 Working Conditions: Climbing - Rarely Concentrating - Consistently Continuous Learning - Consistently Hearing: Conversation - Consistently Hearing: Other Sounds - Consistently Interpersonal Communication - Consistently Kneeling - Rarely Lifting <10 Lbs - Occasionally Lifting 50 Lbs. - Rarely Lifting <50 Lbs. - Occasionally Pulling - Occasionally Pushing - Occasionally Reaching - Frequently Reading - Consistently Sitting - Consistently Standing - Occasionally Stooping - Frequently Talking - Occasionally Thinking/Reasoning - Consistently Use of Hands - Consistently Color Vision - Consistently Visual Acuity: Far - Occasionally Visual Acuity: Near - Consistently Walking - Occasionally Leadership Performance Standards TriHealth leaders create a culture of engagement, safety & reliability and high performance by consistently modeling and utilizing the following TriHealth Way leadership competencies, tactics and ALWAYS Behaviors to drive strategic pillar results: Achievement of Annual Pillar Goals: 1) Safety/Quality, 2) Service, 3) Growth, 4) Culture/People, 5) Finance Leadership Competencies: TriHealth Way of Leading TriHealth Way of Serving Transformation Change Drive for Results Build Organizational Talent Leadership Tactics: Conduct department huddles. Generally, clinical departments hold daily huddles, non-clinical hold weekly huddles. Regularly Round on Team Members, using questions from the rounding log. - 25 or fewer team members = monthly - 26-50 team members = every other month - 51 (and optional team members) = quarterly Lead monthly team meetings using meeting agenda template; review stoplight report; cascade key leadership messages. Model, coach and validate team members’ use of TriHealth Way behaviors (AIDET Promise, Always Behaviors and Always HEARD). Recognize team members for safety wins, positive performance and demonstrating SERVE and ALWAYS behaviors, TriHealth Way of Leading, Serving and Delivering Care. |