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MEDICAL RECORDS CODER I
Job Title: MEDICAL RECORDS CODER I
Job Code: 4096
FLSA: N
Job Level: D2
Revised Date: 08/01/2024
Supervisory Responsibility: No
General Description of the Job Class
Code medical records utilizing ICD-10-CM and CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures.
Duties and Responsibilities of this Level
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions.
Sequence the diagnoses and procedures using coding guidelines.
Ensure DRG/APC assignment is accurate.
Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
Perform other related duties incidental to the work described herein.
Required Qualifications at this Level
Education
High school diploma is required.
In addition, coursework in Medical Terminology, Anatomy and Physiology, with training in medical records coding is required.
Experience
Requires one year of medical records coding experience related to patient records using ICD-10-CM and the CPT-4 coding systems.
A medical records coding certification (see below) or degree in Health Information Management or a related field can substitute for the one year experience requirement.
Degrees, Licensure, and/or Certification
An active/current certification in one of the following areas is preferred, and will substitute for the one year experience requirement:
Certified Coding Associate (CCA)
Certified Coding Specialist (CCS) Hospital Coding
Certified Professional Coder (CPC)
Certified Professional Coder Apprentice (CPC-A)
Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
Certified Professional Coder Hospital (CPC-H)
Knowledge, Skills, and Abilities
ICD-10-CM & CPT-4 coding conventions
Anatomy and Physiology
Medical Terminology
DRG/APC reimbursement
Coding software familiarity
Effective written and verbal communication skills
Data entry/CRT
Distinguishing Characteristics of this Level
N/A
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
