Duke University Job Descriptions
Duke Job Postings
To see if there are current openings for any of the job descriptions listed on this web site, please search Duke Jobs.
MEDICAL RECORDS CODER
Job Title: MEDICAL RECORDS CODER
Job Code: 0097
FLSA: N
Job Level: 90
Revised Date: 01/31/2013
Job Family: JF 07
Occupational Summary
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.
Work Performed
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.
Required Qualifications at this Level
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.
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.
