Responsible for accurate and timely assignment of ICD-10 CM/PCS and HCPCS/CPT codes, payment group classification assignment and data abstraction for reimbursement purposes and statistical information reporting on all Inpatient, Outpatient, Emergency Medicine, Ancillary and Diagnostics records, and/or any other patient records for which HIMS Department performs coding services.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Reviews and interprets Inpatient, Outpatient, Ancillary, Diagnostics and Emergency Medicine or other patient records in order to assign appropriate ICD-10 CM/PCS diagnosis and procedure codes and/or HCPCS/CPT procedure codes as required based on record type and CCHS reporting practices.
Performs coding and abstracting tasks to support accurate and timely billing, data quality and statistics, and to support calculation for severity of illness and risk of mortality reporting.
Follows UHDDS definitions, CMS regulations and Official and Internal coding guidelines.
Utilizes information on diagnostic reports (i.e. radiology, pathology, EKG reports, laboratory values, doctors' orders and administrative medication forms) to accurate code patient charts in accordance with the Official Coding Guidelines.
Completes daily work assignment as directed by Coding Support.
Works within service line structure where applicable based on patient type.
Abstracts pertinent data, determines and sequences codes for diagnoses and procedures, and enters all information into the computerized coding and abstracting system.
Utilizes coding and abstracting system as a communication tool, as outlined in the HIMS Coding DNFB Tagging procedures, including but not limited to placing accounts on hold, to ask questions to management, and initiate queries.
Receives feedback and reviews charts with a member of the Coding Management Team for accurate code assignment.
Provides all necessary coded and abstracted information required for final coding and billing of accounts within productivity expectations by work type in order to support department and organization goals for DNFB dollar amounts and bill hold days.
Reviews prepopulated patient demographic information fed via HL7 from source system into coding system and makes necessary abstracted data changes in coding system as required for accurate posting to CCHS billing system.
Utilizes coding system to calculate all inpatient encounters in both MS DRG and APR DRG groupers to support the accurate reporting of coded data for severity of illness and risk of mortality.
Utilizes coding system to sequence CPT codes invoking the APC grouper methodology to arrive at the proper CPT code hierarchy.
Submits timely, accurate and concise daily productivity reports in accordance with department policy and practice.
Attends and participates in coding section and department meetings, in service training sessions, seminars and workshops.
Reports errors as identified in patient identification, account or encounter information, documentation or other medical record discrepancies as they are noted during daily work performance.
Utilizes general office equipment and computer systems and software applications as necessary to perform work functions.
Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
Performs other related duties as required.
EDUCATION AND EXPERIENCE REQUIREMENTS:
College Diploma in Medical Coding or one year coding experience in a healthcare environment required.
Associate or Bachelor Science degree in Health Information Technology preferred.
Internal Number: JR56982
About ChristianaCare Health System
ChristianaCare Health System is headquartered in Wilmington, Delaware and is one of the country's largest health care providers, ranking 21st in the nation for hospital admissions. Christiana Care is proudly a Nurse Magnet recognized institution. Christiana Care Health System is also one of the largest health care providers in the mid-Atlantic region, serving all of Delaware and portions of seven counties bordering the state in Pennsylvania, Maryland and New Jersey. A not-for-profit, non-sectarian health system, Christiana Care includes two hospitals with more than 1,100 patient beds, and is a major teaching hospital with two campuses. Christiana Care is continually recognized for excellence on a regional and national level. Our role in the community is expressed in the Christiana Care Way: "We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value."Christiana Care is a great place to work because we value diversity and recognize it to be a core part of our success. Because of the diversity of our employees, affiliated health professionals and volunteers, we are ...positioned to meet the unique needs of our patients and community. We acknowledge and celebrate the uniqueness and talent of each employee. Because of our talented workforce we are able to provide a quality healthcare experience to our patients and community. We strive to create an inclusive environment in which individual diversity can be leveraged and thrive. Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.