Description

INPATIENT & AMBULATORY SURGERY MEDICAL RECORDING CODING ; ; Abstracts, codes, and electronically records all diagnoses, surgical procedures, and other significant invasive and non- invasive procedures documented by the physician in any inpatient medical records. May also code Emergency Department and assorted outpatient surgery medical records to assists with outpatient coding backlogs, as needed.

Core Competencies

Reviews the assignment and sequencing of codes for the principal diagnosis, principal procedure, complications and comorbid (CC) conditions, and other significant invasive and non-invasive procedures that should be coded according to ICD-10-CM official guidelines for coding and reporting, published by the U.S. Department of Health and Human Services (DHHS) and the AHA Coding Clinic for ICD-10-CM. Reviews the assignment and sequencing of codes for the principal procedure, other significant invasive and non-invasive procedures according to the coding conventions and guidelines outlined in the CPT code set, the National Correct Coding Initiative (NCCI), the Outpatient Coding Editor (OCE), and the AMA CPT Assistant publication. Applies Medicare Outpatient Prospective Payment System (OPPS) coding assignment requirements regarding the following: Modifiers approved for Hospital Outpatient use, CPT consistent with HCPCS Level II , Medical Necessity Justification (i.e., linking diagnosis to procedure/service performed), Evaluation and Management code assignment, when necessary. Consults with physicians and other healthcare providers to obtain clarification documentation to assist with accurate and complete diagnosis and procedure code assignments. Demonstrates competency in performance of coding functions by maintaining current knowledge in ICD-10-CM, CPT, and HCPCS coding. Assists with the accurate abstraction and the correction of ‘hospital discharge data set’ through the Medical Information Reporting for California (MIRCal) system, in accordance with the regulations administered by the Office of Statewide Health, Planning nd Development (OSHPD). Maintains a daily productivity level according to the benchmarks and standards outline in the HIM department policy and procedure.