Job Description

MISSOURIEN.

CLASSIFICATION SPECIFICATION

CLASS TITLE: MEDICAL RECORDS CODER SUPERSEDES:Medical Records Coder 01/91, 07/86, 02/11, 03/13, 03/18

6333H CODE: REVISED: 01/2019

BASIC FUNCTION AND RESPONSIBILITY

To review, interpret and code medical records, abstract other clinical and demographic data, and enter it into the appropriate university computer application.

CHARACTERISTIC DUTIES

Assign correct code numbers of various illnesses, injuries, operative procedures and diagnostic and treatment techniques in accordance with coding principles of the latest edition of the International Classification of Diseases and Operations, current federal requirements for Diagnosis Related Group (DRG) classifications, hospital policies and procedure classification as defined by the Uniform Hospital Discharge Date Set (UHDDS). Note any irregularities in the assignment of diagnoses as they relate to DRG requirements. Ensure that provider documentation satisfies reimbursement and regulatory agency requirements. Identify problems related to physician documentation for accurate and complete coding. Consult with the Clinical Documentation Specialist to resolve any unspecified or questionable diagnoses prior to final code assignment. Interpret health care documentation in order to determine principal diagnosis and procedure. Provide expert assistance in coding to other hospital departments. Screen medical records for all diagnoses and procedures, including inpatient, outpatient, and physician documentation. Screen record for possible DRG related liability issues. Collect data regarding DRG deficiencies, inconsistencies or omissions.

SUPERVISION RECEIVED

Supervision is received from a supervisor, or Assistant Manager of Medical Records or other designated supervisor.

SUPERVISION EXERCISED

No supervision is exercised.

QUALIFICATIONS

A high school diploma or an equivalent combination of education and experience from which comparable knowledge and abilities can be acquired is necessary. One year of medical coding experience is required. Current enrollment in medical coding program can be substituted for the one year requirement of experience. Completion of program should attained within one year of employment.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs.

PERFORMANCE EXPECTATIONS

This job description is not designed to cover or contain a comprehensive listing of activates, duties or responsibilities that are required of the employee for this job; however, completion of these duties is a measure of successful performance. Employees of this job classification are subject to quarterly performance reviews. Basic function, responsibilities and characteristics duties may change at any time with or without notice.

This document is a general description of typical job duties, responsibilities and qualifications of employees holding the associated job title. Additional duties, specific qualifications and work emphasis may vary between individual positions.