Medical Records Coding Analyst, 20hrs/week, Lincoln
About the position The Medical Records Coding Analyst is responsible for the inpatient and/or outpatient ICD-10-CM and PCS coding functions. Applies appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis and reimbursement of claims. Analyzes inpatient and outpatient medical records including laboratory and radiology requisitions and assigns codes for diagnoses, procedures and symptoms using a nationally recognized coding system, ICD-10-CM. Serves as a liaison between case managers, physicians, and therapists to clarify documentation to achieve accurate coding. Responsible for knowing Medicare and Medicaid regulations, as well as other payer requirements, regarding coding and documentation. Must be able to maintain strict confidentiality. Work will be performed in an ethical and legal manner following organizational policies, processes, and procedures. Responsible for quality service delivery and internal/external customer relations for Madonna as a whole, including upholding the mission and values for the department and facility.
Responsibilities
- Reviews medical record documentation, assigns, and verifies ICD-10-CM diagnosis and procedure codes for all inpatient and outpatient diagnoses and procedures.
- Utilizes an encoder to help ensure accurate and consistent code priority and DRG assignment, using all available references, edits and customized tips.
- Translates clinical documentation using knowledge of anatomy, physiology, disease process and medical terminology.
- Maintains disease and procedure indexes on all inpatients and outpatients by entering ICD-10-CM codes into the abstracting system.
- Contributes to the completion of the Inpatient Rehabilitation Facility - Patient Assessment Instrument by selecting and entering assigned data fields.
- Verifies that all medical records of admitted inpatients and registered outpatients are coded and abstracted.
- Assigns ICD-10-CM codes to symptoms and/or diagnoses from all laboratory and radiology requisitions and enters ICD-10-CM codes in abstracting system where appropriate.
- Reviews medical records concurrently and/or retrospectively and adds diagnosis and procedural codes to capture a complete picture of the patient's condition during their stay at Madonna.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
- Keeps abreast of coding guidelines and reimbursement reporting requirements.
- Completes continuing education to obtain/maintain certification status.
- Assists with data collection and report completion for DRG analysis and qualifying diagnoses analysis.
- Assists with preparation of medical records for review by various internal and external parties.
- Communicates with appropriate individuals regarding the results of documentation and coding quality reviews.
- Identifies learning opportunities and provides education to case managers, physicians and other clinicians based on coding and documentation reviews.
- Provides access to medical records to authorized individuals.
- Answers questions about the medical record content or patient stays at Madonna to authorized internal and external customers.
- Follows instruction from Manager to perform other functions as assigned.
Requirements
- Advanced education from an AHIMA or AAPC accredited program.
- One year ICD-10-CM coding experience with inpatient or outpatient records (preferred).
- For Inpatient: CCS, and/or RHIT (AHIMA), AAPC certification CIC with application work experience.
- For Outpatient: CCS, CCA or RHIT (AHIMA) or COC (AAPC).
- Extensive knowledge of medical terminology, anatomy and physiology, disease pathology and coding principles.
- Attention to detail.
- Knowledge of Medicare and Medicaid regulations and resources.
- Excellent reading, grammar, and organizational skills.
Benefits
- Part Time - Day
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