A Day in the Life
Analyzes each medical record to determine which items will be coded and abstracted. Accurately codes and abstracts inpatient medical records, per work assignment, meeting expected productivity standards
Assigns ICD10-CM diagnosis, ICD10-PCS procedure codes and CPT-4 procedure codes, per established national, departmental guidelines and AHIMA Code of Ethics.
Abstracts and/or edits medical record data as required by departmental guidelines. Assigns and enters charges for ER EM levels, infusions, injections, and procedures per departmental guidelines.
Communicates with physicians and Clinical Documentation Integrity Specialists to request clarification and/or additional record information that will ensure correct code assignment, appropriate reimbursement, and compliance with established guidelines. This applies to ICD10 and CPT coding.
Maintains organized system for personal coding reference material. Participates in educational activities and maintains coding skills.