Using established coding principles and procedures reviews analyzes and codes diagnostic and/or procedural information from the patient’s medical record for reimbursement/billing purposes. Accurately abstracts information from the medical record for compilation of a patient database, which supports medical research projects, patient care evaluation and administrative decision making related to patient care. The coding function is considered a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement. The coding function also ensures compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines. PRINCIPLE DUTIES AND RESPONSIBILITIES: - Identifies all diagnostic and operative procedures for coding by thoroughly reviewing the patient’s medical record, including histories, physicals, operative reports, diagnostic testing reports, pathology reports, therapy notes and discharge summary, etc. - May analyze provider documentation to assign or verify the appropriate Evaluation & Management (E&M) CPT code. - Verifies and/or requests documentation to support compliance. - Assigns diagnostic and procedural codes in accordance with coding principles and established guidelines. - May review and correct coding errors, edits, rejections and/or disputes. - Charge entry when appropriate. - Performs a comprehensive review of the documentation to ensure the presence of all necessary elements, such as: patient identification, provider signatures and dates. - Verifies completeness of medical record within electronic medical record, reporting any discrepancies to supervisor. - Interacts with medical staff via physician queries for clarification of documentation. - Performs other related duties as required - If participating in the remote coding program, required to adhere to the Remote Coding Program Policy (Medical Record Services Policy 09). - Maintains a working knowledge of applicable Federal, State and local laws and regulations, the Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. EDUCATION/ EXPERIENCE REQUIRED: - High School Diploma or G.E.D. equivalent required. - Additional specialty coding certification required or Bachelor’s Degree required. - One to two (1-2) years college or additional coursework in Accounting, Business, Healthcare Administration or Medical Record Sciences preferred. Must have a thorough knowledge of anatomy, physiology, pathophysiology, disease processes, medical terminology, pharmacology, and coding systems. Minimum of two (2) years coding experience required. Specialty coding experience preferred. CERTIFICATIONS/ LICENSURES REQUIRED: Certification as a Registered Health Information Technician (RHIT), CPC, or CCS certification required. Additional Information Organization: Henry Ford Hospital - Detroit Main Campus Department: Radiology-Administration Shift: Day Job Union Code: Not Applicable