STATEMENT OF PURPOSE:

To ensure correctness of data submitted for reimbursement by reviewing encounter data for accuracy and completeness and assigning numeric codes for each diagnosis and procedure.

ESSENTIAL FUNCTIONS:

• Receives completed daily folders from each facility/department and analyzes each for completeness, accuracy of input and compliance with SLFHC policy and rate schedule


• Reviews patient records and assigns numeric codes for each diagnosis and procedure


• Reads and analyzes medical records to help identify all diagnoses and procedures relevant to the current episode of patient care


• Researches encounter integrity for ICD-9, ICD-10 and CPT links and corrects if necessary


• Confirms encounter information and obtains missing information by reviewing the patients medical records chart


• Clarifies inconsistent, ambiguous or non-specific information in a medical record by consulting with the supervisor or the responsible medical practitioner


• Confirms codes to patients current episode of care


• Notifies Lead Certified Medical Coder when training issues are discovered


• Formulates training sessions or literature pertaining to coding and input issues