Coder Level 4-PACC Medical Records (Remote)-Mount Sinai Union Square

Description

Coder Level 4-PACC Medical Records (Remote)-Mount Sinai Union Square-Full Time, Days

Responsible for coding of inpatient and/or ambulatory surgery records utilizing ICD-10-CM and ICD-10-PCS or CPT coding guidelines and conventions for the establishment of diagnoses and procedures. The coded information is utilized for reimbursement purposes, data retrieval, education, to support medical research activity, assessment of clinical care, evaluation of medical services, case mix for the facility, and identification of health care concerns for public health

Responsibilities

Thoroughly review, analyze, and interpret the entire medical record (electronic and hardcopy), including progress notes, consultation reports, physician orders, nursing notes, operative reports, pathology reports, radiology reports, laboratory results, medication records, other ancillary service reports, and the discharge summary to identify all diagnoses and procedures occurring/affecting the current admission

Apply knowledge of anatomy and physiology, disease process, pharmacology, to identify diagnoses and procedures documented in the medical record

Apply knowledge of the ICD-10-CM and CPT-4 coding system to translate identified diagnoses and procedures to codes for accurate reimbursement and data.

Adhere to Official ICD-10-CM and CPT-4 Coding Guidelines when identifying diagnoses and procedures.

Abstract information regarding congenital malformations for reporting to the Congenital Malformations Registry (CMR) as mandated by New York State.

Utilize all available resources to assist coding and reimbursement to the facility, including but not limited to AHA, AMA, AHIMA and CMS, ICD-10-CM Coding Handbook, CPT-4 Procedural Handbook, electronic reference material available in 3M encoder, and institutional coding policies

Alerts the Coding Manager when the medical record documentation requires further clarification

Use 3M 360 encoder logic and grouper software to assign diagnosis and procedure codes. Utilize the clinical analyzer to assist in refining and focusing on reimbursement under the DRG payment system

Maintain and continually enhance and update coding skills and knowledge by participating in continuing education programs to support the effective application of ICD-10-CM, CPT-4 and coding guidelines to outpatient diagnoses and procedures. This is extremely important due to the fast pace of technological and clinical advances in the medical field and in retaining credentials.

Abide by all Federal and state regulations, as dictated by CMS, Medicaid, and other third party payers regarding reimbursement for the facility

Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).

Maintain confidentiality of all patient records and medical and other information.

Qualifications

High School education, Associate degree preferred.

Minimum 7+ years inpatient coding experience in tertiary care hospital

CC3 required ? IP or CCS-P, CCS, CPC-H or CPC required for OP

SEIU 1199 at Mount Sinai Beth Israel and MS Downtown, AKZ - PACC Medical Records - USD, Union Square - Downtown