Job Facility: University of Maryland Medical Center
Employment Type: Full Time
What You Will Do:
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.
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.
Coding diagnoses and procedures of discharged outpatient patient records using either the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), the Current Procedural Terminology (CPT-4) or other relevant and approved classification systems, maintaining a 95% accuracy rate. Enters assigned codes into computer abstracting system. Processes a minimum of 50 charts per day.
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.
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 statutes, 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.
What You Need to Be Successful:
Education and Experience
Minimum of Certificate in Coding (Certified Professional Coder [CPC]) or eligible to sit for certification within one (1) year is required.
Knowledge, Skills and 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 personal computer and other routine office equipment.
Ability to maintain 95% coding accuracy rate and to code a minimum of 50 charts per day.
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.