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Become A Medical Record Coder

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Working As A Medical Record Coder

  • Getting Information
  • Processing Information
  • Documenting/Recording Information
  • Interacting With Computers
  • Organizing, Planning, and Prioritizing Work
  • Mostly Sitting

  • Repetitive

  • $63,565

    Average Salary

What Does A Medical Record Coder Do At Cigna

* Supplies correct ICD
* CM/ICD-10-CM diagnosis codes on all diagnoses provided
* Accurately follows coding guidelines
* Performs other related duties, which may be inclusive, but not listed in the job description
* Perform coding work requiring independent judgment with speed and accuracy
* Communicate clearly and concisely, orally and in writing
* Ability to use the computer
* Ability to work independently to accomplish assigned work within the allocated time
* Ability to communicate with staff and supervision, both in person, in writing and over the telephone, in a tactful manner
* Understanding and carrying out verbal and written directions
* Follow Cigna
* HealthSpring and departmental policies and procedures

What Does A Medical Record Coder Do At Duke University

* Review medical record documentation and accurately assign codes for the primary/secondary diagnoses and procedures using ICD
* CM, ICD-10-PCS, CPT-4 and HCPCS Level II.
* Sequence diagnoses and procedures using coding guidelines.
* of time spent
* Maintain competency in ICD
* CM, ICD-10-PCS, CPT-4 and HCPCS Level II and knowledge of reimbursement reporting requirements.
* Maintain a thorough understanding of anatomy and physiology, medical terminology, pharmacology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD
* CM coding guidelines for assignment of outpatient diagnoses and CPT
* and HCPCS Level II for procedures.
* Knowledge coding and charging requirements to ensure accurate code submission along with management of edits and denials.
* Knowledge of UHDDS definitions and data requirements to support accurate coding and data collection.
* Knowledge of NCD/LCD edits to support compliance with medical necessity requirements.
* Apply knowledge of all coding reference materials and education to problem solve unique or new cases resulting in the assignment of appropriate diagnosis and procedure codes.
* of time spent
* Use logic and reasoning to demonstrate critical thinking in the assignment of diagnosis and procedure codes with consideration for reimbursement, quality and other data capture requirements.
* of time spent
* Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
* of time spent.
* Maintain compliance with quality and quantity standards as outlined in DUHS HIM Coding Policies.
* Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
* Perform other related duties incidental to the work described herein.
* Location:
* Durham
* Exempt/Non
* Exempt:
* Non-exempt
* Requisition Number:
* Position Title:
* HIM MEDICAL RECORDS CODER II - INPATIENT
* Shift:
* First/Day
* Job Family Level:
* E2
* Full Time / Part Time:
* FULL TIME
* Regular / Temporary:
* Regular
* Department Name:
* DUHS HIM CODING

What Does A Medical Record Coder Do At SUNY Downstate Medical Center

* The Medical Records Coder will perform abstracting and coding, using ICD
* CM and CPT, on all Ambulatory Surgery cases at SUNY Downstate Medical Center and SUNY Downstate Medical Center at Bay Ridge.
* The incumbent will ensure that accounts are coded accurately utilizing the 3M encoder and Alpha System computer systems.
* Perform related duties as assigned to meet operational needs.
* Work collaboratively and maintain effective working relationships in the department and across the Health System
* DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION
* All successful candidates must undergo various background checks, maintain credentials required for continued employment and adhere to the SUNY
* DMC UHB Principles of Behavior.
* Clinical Faculty and Allied Health professionals must receive and maintain Medical Board authorization

What Does A Medical Record Coder Do At Northwell Health

* 1. Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
* Utilizes resources and reference materials (e.g., on-line sources, manuals) to identify appropriate codes and reference code applicability, rules and guidelines.
* Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient’s acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record.
* Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures in accordance with the established International Classification of Diseases 10 th Revision Procedure Classification System (ICD
* PCS) Official Guidelines for Coding and Reporting.
* Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.
* Make determinations on medical charting and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process
* Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment
* Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations.
* For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.
* Assigns appropriate discharge physician in the system.
* Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations.
* Demonstrates basic knowledge of the impact of coding decisions on revenue cycle.
* Maintains the minimum data standards for accuracy and efficiency as defined by the facility.
* Performs related duties, as required
* ADA Essential Functions
* Qualifications

What Does A Medical Record Coder Do At University of Rochester

Responsibilities

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How To Become A Medical Record Coder

Health information technicians typically need a postsecondary certificate to enter the occupation, although some may need an associate’s degree. Certification is often required.

Education

Postsecondary certificate and associate’s degree programs in health information technology typically include courses in medical terminology, anatomy and physiology, health data requirements and standards, classification and coding systems, healthcare reimbursement methods, healthcare statistics, and computer systems. Applicants to health information technology programs may increase their chances of admission by taking high school courses in health, computer science, math, and biology.

A high school diploma or equivalent and previous experience in a healthcare setting are enough to qualify for some positions, but most jobs for health information technicians require postsecondary education.

Important Qualities

Analytical skills. Health information technicians must be able to understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise caution and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must be able to use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted.

Licenses, Certifications, and Registrations

Most employers prefer to hire health information technicians who have certification, or they may expect applicants to earn certification shortly after being hired. A health information technician can earn certification from several organizations. Certifications include the Registered Health Information Technician (RHIT) and the Certified Tumor Registrar (CTR), among others.

Some organizations base certification on passing an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, technicians typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be licensed. Licensure requires the completion of a formal education program and the Certified Tumor Registrar (CTR) certification.

Advancement

Health information technicians may advance to other health information positions by receiving additional education and certifications. Technicians may be able to advance to a position as a medical or health services manager after completing a bachelor’s or master’s degree program and taking the required certification courses. Requirements vary by facility.

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Medical Record Coder jobs

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Medical Record Coder Demographics

Gender

  • Female

    86.3%
  • Male

    11.4%
  • Unknown

    2.3%

Ethnicity

  • White

    77.8%
  • Hispanic or Latino

    11.0%
  • Asian

    7.5%
  • Unknown

    2.9%
  • Black or African American

    0.8%
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Languages Spoken

  • Spanish

    60.0%
  • Igbo

    20.0%
  • French

    20.0%

Medical Record Coder

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Medical Record Coder Education

Medical Record Coder

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Top Skills for A Medical Record Coder

ElectronicMedicalRecordProcedureCodesDiagnosisCodesGuidelinesEmergencyCPCComplianceOutpatientSurgeryAuditDiseaseProcessesMedicalChartsHealthInformationAssignIcd-9-CmDRGCpt-4RadiologyRecordsCoderClinicalStaffPhysiologyAnatomy

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Top Medical Record Coder Skills

  1. Electronic Medical Record
  2. Procedure Codes
  3. Diagnosis Codes
You can check out examples of real life uses of top skills on resumes here:
  • Identified the primary and secondary diagnoses and primary and secondary procedure codes (when applicable) for every outpatient encounter.
  • Skilled in abstracting data from electronic medical records and assigning diagnosis codes in compliance with AHA and CMS.
  • Followed complex set of outpatient coding guidelines and applied ethical standards.
  • Specialized in Emergency Medicine and Critical Care.
  • Obtained the CPC-H (Certified Professional Coder - Hospital) credential

Top Medical Record Coder Employers