Coder IV

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Job Description Summary:

This position performs facility coding and abstracting functions of Inpatient.Responsibilities And Duties:

1. 60% Assigns appropriate admit, & principal and secondary diagnoses and/or procedure codes by reading documentation present in medical record and applying knowledge of correct coding guidelines as appropriate for hospital service and/or patient type while maintaining

95%

quality and meeting and maintaining the minimum Coder productivity requirements. Assign Present on Admission PO a indicators to all inpatient account diagnoses as required by official coding guidelines. Accurately Assign DRG/MSDRG/APR-DRG at the minimum standards of 95% Review Diagnosis and CC/MCC for maximum SOI/ROM Clinical understand of laboratory and radiology values Knowledge of quality outcomes indicators Work with CDS to improve physician documentation and case mix index Assign Principal Diagnosis accurately at least 95% or better Monitor and appropriately assign HAC codes when appropriate Responsible for recognizing when it is necessary to obtain further clarification from physician when documentation is inadequate, ambiguous, or unclear for coding purposes. Assists educators and supervisors with reviewing accounts denied by RAC and other governmental payers for appropriate documentation to support original coding. 2. 20% In the event of insufficient, missing or conflicting documentation, assigns transaction codes in HBOC system and follows department policy for follow up and physician query. 3. 10% : Abstracts all data elements necessary to complete UB0 4 and meet hospital-reporting requirements. 4. 5% : Verifies demographics, corrects account number, charges and service and identify missing or incorrect forms in each record. 5. 5% : Identifies problem cases on the DNFB and forwards to appropriate staff for follow up. The major duties, responsibilities and listed above are not intended to be all-inclusive of the duties, responsibilities and to be performed by employees in this job. Employee is expected to all perform other duties as requested by supervisor.