GENERAL SUMMARY
Responsible or applying the appropriate diagnostic and procedural codes to individual patient health information for
data retrieval, analysis, and claims processing.
ESSENTIAL FUNCTIONS
Abstracts pertinent information from patient records. Responsible for assignment of ICD-9 and/or CPT codes
to all inpatient, observation, outpatient surgery, emergency room and ancillary department discharges.
Queries physicians when code assignments are not straightforward or documentation in the record is
inadequate, ambiguous, or unclear for coding purposes.
Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified
documentation concerns to supervisor or department manager for resolution.
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management
Association and adheres to official coding guidelines.
Maintains confidentiality of patient and hospital related business
Develops and maintains an effective working relationship with patients, families, visitors and other hospital
employees.
MINIMUM KNOWLEDGE AND SKILLS REQUIRED
One to three years experience in a clinic setting utilizing ICD-9 and CPT codes.
Know the definitions of fundamental computer terms related to applications software and
desktop PC's
Know how to open, read, and respond to email
Know how to manage electronic files
Know how to print electronic documents and reports
MINIMUM EDUCATION AND EXPERIENCE REQUIRED
One to three years coding experience.
CPC certification preferred
LICENSURE AND CERTIFICATION
Current CPC certification preferred.
ENVIRONMENTAL AND PHYSICAL REQUIREMENTS
Works in temperature controlled environment.
Must to able to read, write and speak English fluently, have cognitive skills for math, reading, filing and sterile
technique skills. Vision for near, mid-range, far and accommodation. Hearing for low, medium, and high
pitch.
Communication skills to deal well with employees, patients, families and physicians.
Requires physical ability for standing, sitting, crouching, kneeling, frequent walking, reaching above head and
below waist.
Ability to lift 25 pounds.