Medical Records Technician (Coder)

Performs comprehensive quantitative analysis by reviewing written, dictated and electronic· clinical documentation records to assure the presence of all component parts of the ambulatory or inpatient visit record; including patient demographics, correct identification and validation of each part by name, health record number, signatures and dates where required, and the presence of all reports which appear to be indicated by the treatment rendered, diagnosis and procedures performed, and compliance with hospital policy, medico legal, medical necessity and regulatory requirements.Performs comprehensive qualitative analysis by evaluating the ambulatory or inpatient visit record for documentation consistency and adequacy. Ensures the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies, special screening criteria, inconsistencies or discrepancies are addressed with the appropriate healthcare provider.Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology diagnostic and procedural terminology and coding guidelines to assign codes accurately to diagnoses and procedures in accordance with official coding guidelines. Utilizes the PCC automated encoder coding books, coding conventions/guidelines, internet resources to assigns and sequences a variety of codes including but not limited to ICD-9-CM/ CPT/ HCPCS/ICD-10-CM/ICD-10-PCS codes based on the medical record analysis. Assures the final diagnoses and procedures as documented by the provider are valid and complete. When multiple diagnoses and procedures are listed, assures the procedure is related to the proper diagnosis.Performs audits for or in conjunction with the facility Compliance plan and Performance Improvement study designs, medical records review process, and utilization review process which may include findings from provider documentation trends, coding peerreviews and reimbursement denials. Provides reports of findings, education and feedback to parties involved and may participate in committees, work groups, teams and ' discussions with medical, nursing and other staff regarding coding, reimbursement and documentation issues.Runs weekly error reports to ensure data is transported to the data center. Makes corrections to the error reports by validating orphaned visits in the database. Performs audits which may include findings from provider documentation trends, coding peer reviews, and reimbursement denials. Provides reports of findings and feedback to parties involved.