Evaluates medical records and charge tickets to ensure completeness, accuracy, and compliance with the ICD-10-CM, and CPT coding guidelines. Provides technical guidance and training on medical coding to physicians, Clinicians and staff; and performs related duties as instructed by supervisor.
DUTIES AND RESPONSIBILITIES (not all inclusive):
- Evaluates medical record documentation and charge ticket coding to optimize reimbursement by ensuring diagnostic and procedural codes and other documentation accurately reflect and support the outpatient treatment/procedure/visit, and to ensure that the documentation complies with legal standards and guidelines.
- Interprets medical information such as diseases or symptoms, and diagnostic descriptions and procedures in order to accurately assign and sequence the correct ICD-10-CM and CPT codes.
- Compares reimbursement claim detail with clinical documentations for completeness/accuracy.
- Evaluates records and prepares reports on coding or documentation issues for review.
- Provides technical guidance to physicians and other staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines.
- Educates and advises staff on proper code selection, documentation, procedures, and requirements.
- Identifies training needs, assists in preparing training materials and conducting training for physicians and support staff.
- Maintains up-to-date procedure manuals to maintain standards for correct coding
- Other duties as assigned.
High school diploma or equivalent. Two years of experience in medical record coding; or, equivalent combination of experience, education, and training that would provide the required knowledge and abilities. CPC-A, CPC-H, CPC, or CCS. Knowledge of: ICD-10-CM, and CPT coding guidelines; medical terminology; anatomy and physiology; Medicare and Medicaid reimbursement guidelines.
Process Strategies is an Equal Opportunity Employer.