Macon, GA, United States
Job ID: 109024
Job Family: Medical Records Services
Status: Full Time
Job Type: Regular
Department Name: 32491084041265-Central Billing Office - Coding
Reviews records post discharge to assign diagnoses and procedures for outpatient surgery, outpatient procedure, outpatient encounters, physician encounters, and medical observation. Assigns correct diagnosis codes and outpatient procedure codes while maintaining department productivity and quality goals. Abstracts all data elements required for billing.
Reviews outpatient charts, including both written and electronic medical record information,
utilizing coding methodology , disease process and pathophysiology, and any internal software
applications. Ability to understand and interpret medical terminology and anatomy/physiology.
Determines accurate code selection for all diagnoses and procedures based on documentation in
the medical record in accordance with AMA coding guidelines with at least 95% accuracy.
Utilizes 3M Encoder for coding all diagnoses and procedures
Abstracts all required data elements needed for hospital billing or professional billing including
discharge disposition, attending MD, and consulting MD in the Medical Record Abstract with at
least 95% accuracy.
Uses Coding Clinic and other available coding material as a resource tool.
Resolves questions concerning diagnoses, procedures, content of record or code selection
Education, Training, and Experience:
Must be a High School or GED Diploma Graduate. College degree is preferred (Healthcare Information Management or Business). Successful completion of Anatomy and Physiology and Medical Terminology courses is required.
Formal training in diagnosis and procedural coding is required.
Minimum of two years coding experience is preferred.
RHIA, RHIT, CCS or CPC is required.