• Compile, abstract and maintain patient medical records to document condition and treatment. Actively code diagnoses (ICD-9) based on medical record documentation.
• Assign codes (ICD-9, 10, CPT, and HCPCS) that accurately describe diagnoses, procedures, and therapies according to established guidelines.
• Review records for completeness, accuracy and compliance with regulations. Protect the security of medical records to ensure that confidentiality is maintained.
• Participate in inter-rater reliability testing/peer review exercises, as requested.
• Other duties as assigned or requested.
• Associate degree in medical record technology or 1-year medical coding diploma,
• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)
• Exposure to commercial claims and/or medical/surgical products or Medicare advantage or Medicare fee for service program coverage, the Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-9, ICD-10) information.
• Knowledge of coding International Classification of Diseases, 9th Revision (ICD-9) codes.
• Understands and applies appropriate Centers for Medicare & Medicaid Services (CMS) guidelines to coding.
• Knowledge of anatomy, physiology and medical terminology.
• Coding software familiarity.
• Excellent verbal, math and written communication skills.