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Duke University Job Description: |
Job Title: MEDICAL RECORDS CODER |
Job Code: 0097 |
FLSA: N |
Job Level: 90 |
Revised Date: 01/31/2013 |
Job Family: JF 07 |
Responsible for the coding of Anesthesiology patient charges from the operative reports to be entered into the IDX Anesthesia Module for billing purposes. Audits records and charges for accuracy. Assist Business Services with billing issues. Identifies Anesthesiology charging and documentation issues and relates these to the appropriate faculty.
Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the procedures from the operative reports using CPT coding conventions.
Reconciles the number of charge sheets received in the OR, ASC, Eye Center, etc. daily census, against OR schedules for accuracy.
Reviews patient charts for completeness and verifies that all information is accurately documented on the charge sheet
Documents additions and corrects errors to charge sheet according to departmental standards
Communicates with faculty about necessary documentation for accurate charging and billing
Provides technical charges to hospital Charge Processing for Anesthesia room charge and Anesthesia Minutes.
Enters appropriate patient charge codes into IDX.
Trains new faculty on the charging practices and documentation standards for the department
Provides support to Billing, Patient Accounting, and insurance representatives to assist with billing issues and patient inquiries
Maintains an understanding of medical record practices, standards, and regulations
Assist in developing current written policies, procedures, and guidelines
Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply CPT coding guidelines to inpatient and outpatient procedures.
| Education/Training: | 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-9-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. 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) |
| Skills: | ICD-9-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 |
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.
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