St Josephs Healthcare System

Abstract Coder

Requisition ID
2016-2290
Shift
Day
Category
Health Information Management/Medical Records
Shift Hours AM/PM
N/A
Department
SJ MED RECS
Position Type
Regular Full-Time

Overview

St. Joseph’s Healthcare System is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.

 

 

Job Overview

 

Under general supervision and according to established policies and procedures, reviews and abstracts the demographic, financial and clinical data from the inpatient medical record for the purpose of assigning ICD-9-CM diagnosis/procedures, HCPCS, and CPT4. Ensures that inpatient and outpatient records are coded, abstracted and entered into computer system in an accurate and timely manner.

Responsibilities

Reviews medical record thoroughly to ascertain all diagnosis/procedures. Codes all diagnoses/procedures in accordance to ICD-9-CM coding principles and CPT procedural coding guidelines. Abstracts and enters information into computer systems to ensure compliance. Productivity Standards: IP Functions: coding/abstracting/physician queries (AVG/day)-12-18; SDS/SDM/Minor OR Functions: coding/abstracting/physician queries (AVG/day)-25-40; ED Functions: coding/abstracting/charge entry (AVG/day)-80-100; ED functions: coding/abstracting (AVG/day)-100-120; Ancillary Functions: coding/retrieve information from DI or Invision or script/medical necessity (AVG/day)-160-200. Maintains 99% rate of information abstracted and entered information into computer system. Retrieves and reviews all missing pertinent clinical testing (pathology, x-rays and other testing results) and maintains quality of 95%. Reviews coding materials in a timely manner and applies information appropriately. Utilizes Local Determination Coverage (LCD) documents to promote accurate and compliant outpatient coding. Abstracts and enters the required data in the medical record abstracting computer system, ensuring that integrity of the data, in accordance with hospital procedure with documentation. Contacts responsible physician in a professional and tactful manner, if diagnosis verification of POA is not available or clearly documented in the medical record. Completes Physician's Query Form when appropriate & follow-up as required. Identifies records of patients with malignant disease and insure that proper tagging to Cancer Registry is done. Assist in coding, abstracting all work assignments. Participates as a weekly team leader, providing for distribution of workflow and support to other coding staff. Notifies Senior Lead Coder/Coding Manager if there is question or discrepancy regarding diagnosis or procedure with documentation. Meets all required competencies for department, unit and/or hospital. Responsible for performing all other duties as assigned. Special Projects

Qualifications

Work requires the level of knowledge normally acquired through completion of two to three years of occupational-specific education beyond High School or an Associate’s Degree in Medical Record Technology or a closely related field and three to six months of previous work related experience. Work requires the analytical ability to resolve problems that require the use of basic scientific knowledge. Work requires the ability to exchange information on factual matters.

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