Working from the appropriate documentation in the medical record, assigns codes and modifiers with ICD-9-CM, CPT, and HCPCS Level II codes where needed. When assigned, review and if necessary correct codes that have been assigned by an Outpatient/Ambulatory coder to ensure that they have been completed in accordance with the rules, regulations, and coding conventions of ICD-9 CM official guidelines for coding and reporting, Coding Clinic published by the American Hospital Association, the ICD-9-CMcode book, CPT, CPT Assistant, CMS, NCCI edits, and OSHPD.
Under supervision, codes all diagnostic and operative information from the medical record using ICD-9-CM, CPT and HCPCS coding classification systems. Verifies and abstracts all medical data from the record to complete a data abstract on encounters in the following settings: Emergency Department (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV).Corrects data as appropriate. Ensures that all data abstracted and coded are consistent with ICD-9-CM Official Guidelines for Coding and
Reporting, as well as those guidelines outlined by CPT, CPT Assistant, CMS, UHDDS, JCAHO, NCQA, OSHPD,
Ensures timely record completion by meeting coding and abstracting productivity/quality standards. Participates in medical record documentation auditing to monitor physician compliance with regulator requirements i.e., Physician Review Project in concert with appropriate managers. May provide physician review and education based on review findings. Quality Standards Measured bi-weekly and reported in 4-week increments: Average weekly between 85 - 90 simple HOV charts/day Average weekly between 85 – 90 ED charts/day Average weekly between 35 – 45 Ambulatory Surgery & complex HOV charts/day Average weekly between 10 12 Edit Correction charts/hour Based on audits of 20 or more charts per year: 95% DRG/APCs 95% principal diagnosis 98% discharge disposition.
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