Job Facility: University of Maryland Medical Center
Employment Type: Full Time
What You Will Do:
This DRG Specialist will support INPATIENT coding. General Summary Under general supervision, analyze and evaluate medical records according to licensing and accreditation requirements; code symptoms, diseases, operations, procedures; maintain and utilize medical record indexes and storage and retrieval systems; maintain patient information according to confidentiality policies and procedures; and, compile administrative and health statistics for reimbursement purposes, quality assurance and medical research using manual or computer methods.
Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
Record maintenance. Reviews record for completeness, accuracy and compliance with documentation standards of federal, state and accreditation agencies.
Assigns deficiency code to deficient record and identifies responsible physician.
Codes diagnoses and procedures of discharged patient records using either the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), the Current Procedural Terminology (CPT-4) or ICD-0 or other relevant, approved classification system, maintaining a 95% accuracy rate. Enters assigned codes into computer abstracting system. Processes a minimum of 25 charts per day.
Assigns and verifies Diagnosis Related Group (DRG) assignments using Codemaster--computerized code book software.
Abstracts data from the medical record through intensive medical record review and enters information into the computer abstracting system for billing/reimbursement purposes and the compilation of administrative and clinical statistics.Completes the automated Medical Record Abstract form for Health Services Cost Review Commission (HSCRC) reporting and the Medical Assistance 3808 Form.
Maintains accurate physician information, diagnostic and procedural codes for resource purposes.
Contacts nursing and medical staff to clarify questions concerning documentation in patient records to ensure accuracy and consistency of coding, abstracting or other purpose.
Assures data quality through accuracy, consistency and completeness of coding and abstracting functions.
Applies federal and state statues, UMMS and departmental policy to retention of records and patient confidentiality. Observes Medical System and departmental policies and procedures.
Maintains accurate and up-to-date coding and abstracting manuals.
Compiles and submits to supervisor accurate records of individual, daily work production. Meets established productivity standards.
May assist in transcribing priority tapes, reviewing transcribed notes returned from transcription service for accuracy and completeness or coordinate all the transcription functions for the particular unit; responds to requests for release of patient information; may engage in special projects at the request of the supervisor (primarily satellite units).
What You Need to Be Successful:
Education & Experience:
High School Diploma or equivalent required. Associate's degree in Health Information Technology or an independent program in Health Information Technology preferred.
Current accreditation by the American Academy of Professional Coders (AAPC) or American Medical Record Association (AHIMA) as RHIT/RHIA, CCS, CCS-P or CPC required.
One (1) year ICD-9-CM coding and abstracting experience in an acute care environment.
Knowledge, Skills & Abilities:
Knowledge of medical record practices, state and federal laws relating to release of medical information, ICD-9-CM and CPT coding systems, medical terminology to understand diagnoses and procedures, and the content and organization of a medical record.
Knowledge of anatomy, physiology and disease process to understand and interpret diagnoses and procedures contained within, discharge summaries, operative and laboratory reports and related medical documents.
Knowledge of typewriter/word processor, personal computer and other routine office equipment. Knowledge of computerized dictating systems preferred.
Ability to maintain a 95% coding accuracy rate.
Effective oral and written communication skills are required to work with medical, nursing, and other allied health staff as well as external medical facilities requesting medical record information.