Facility

Cape Fear Valley Urology

Location

Fayetteville, North Carolina

Department

Cape Fear Valley Urology

Job Family

Clerical

Work Shift

Days (United States of America)

Summary

Reviews thoroughly the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Codes all diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter

• Performs medical record abstracting of hospital admissions for reimbursement and statistical reporting

• Verifies patient data while abstracting for accuracy and completeness of patient database

• Refers to the Local Medical Review Policies, National Determination Coverage Policies and Local Determination Coverage Policies, as necessary, to ensure compliance with federal guidelines

• Assesses OCE, NCCI and CCI edits, as necessary, to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts for accurate claim submission

• With full understanding of PPS regulations, the DRG classification systems (MS-DRG and APR-DRG), and CMS Patient Safety and Quality initiatives, communicates with physicians regarding the accuracy of principal and secondary diagnoses on the final code set, based on lab and other diagnostic findings, when the record may be subjected to QIO review due to vague attestation/documentation

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• High school diploma or equivalent required

• Associates degree preferred

Work Experience: 

• Applicants without Associate degree requires 2 years of ICD-CM/CPT-4 coding experience

Knowledge, Skills, and Abilities Required: 

• Good data entry skills

• Familiarity with medical record content and understanding of ICD-CM/CPT4 coding principals

• Ability to assign accurate codes using good judgement within broad guidelines

• Flexible and capable of intense concentration in a busy, noisy and crowded environment

Physical Requirements: 

• Near visual acuity

• Motor coordination to operate computer

• Most work is sedentary

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity