Solutions / Coding & Abstracting (onsite and/or offsite)

  1. Review medical records to identify diagnoses/procedures.
  2. Comprehensive, knowledge of all guidelines concerning sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
  3. Code all diagnostic and operative information from the medical record in accordance with the rules, regulations and coding conventions of the American Hospital Association (Coding Clinic), ICD-10, CPT, HCPCS coding classification systems and consistent with guidelines outlined by JCAHO, OSHPD and CMS, regional and local policy.
  4. Selects the DRG for each inpatient case.
  5. Knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated encounters/cases.
  6. Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
    1. Verify and abstract all data from medical record to assign appropriate codes for the following settings: Hospital Emergency (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV) and Medial Office
    2. Codes all diagnostic and operative information from the medical record in accordance with the rules, regulations and coding conventions of ICD-10 Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-10, CPT and HCPCS coding classification systems, CPT Assistant, NCCI Edits, OSHPD and organizational and institutional coding guidelines
    3. Identify and resolve coding related edits by reviewing the medical record and ensuring that all data and codes are consistent with ICD-10 Official Guidelines, CPT, CPT Assistant, CMS, OMFS, MediCal, USDOL, as well as Regional and Local policies.
  1. Family Practice (Internal Medicine, Pediatrics)
  2. Obstetrics /Gynecology
  3. Radiology / Interventional Radiology
  4. Cardiology
  5. Oncology
  6. Urology / Nephrology
  7. Gastroenterology
  8. Dermatology / Plastic / Cosmetic Surgery
  9. Ophthalmology / Otolaryngology
  10. Orthopedic
  11. Neurology
  12. Anesthesiology
  13. General Surgery / Hospitalist
  14. ...etc.

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