Maintains strict confidentiality in compliance with facility policy and procedure, the Health Insurance Portability and Accountability Act (HIPAA) and State-specific confidentiality requirements.
Responsible for the coding of assigned diagnosis and/or procedure codes for all inpatient encounters, capturing the most accurate diagnosis and/or procedures with the greatest degree of accuracy and completeness.
Review at a minimal, the following documents in order to assign the most accurate diagnosis and/or procedure codes for inpatient encounters:
History and Physical (H&P)
Operative/ECT Report, if an operation is performed
Pathology/Cytology Report, if a specimen is removed during the operation
All progress notes
All physician's orders
Discharge Summary (if this would impact the DRG: e.g., need for Complications and Co-morbidities)
Consultation Report, if indicated
Assessment Department documentation
Laboratory results, if ordered
Nursing Discharge Note for patients that are transferred
Adheres to the most recent International Classification of Diseases (ICD) for coding.
Adopts and adheres to American Health Information Management Association's Code of Ethics, as well as their Standards of Ethical Coding.
Uses the Physician Query Form to obtain clarification from the attending physician on any coding questions, including the reference to source documentation.
Support facility internal and external customer service standards.
Adheres to all facility policies and procedures.
Enters data into computer systems.
Answers telephone calls pertaining to coding and medical records.
Demonstrates an understanding of the importance of the Pavilion Mission Statement in performing all aspects of this position.
Demonstrates a caring and helpful attitude when interacting with internal and external contacts.
Strives to build cooperative partnerships by treating each person both inside and outside of the organization as a customer.
Establishes and maintains effective working relationships with other personnel.
Participates in maintaining departmental continuous quality improvement.
Fills in for coworkers scheduled and unscheduled time off, if necessary.
Performs other duties as assigned.
The above statements are not intended as an exhaustive list of all job duties, responsibilities and requirements.