York, PA | Clerical and Administrative | Tracking Code: 86585

Coder/Billing Specialist

General Summary:



Under direct supervision, performs a variety of functions including coding/abstraction, charging, data collection,

assembly and analysis of medical records to establish and maintain a patient medical database to support medical care,

statistical and administrative needs. Reviews treatment record to determine level of payment.



Duties and Responsibilities:


1. Abstracts from patient chart designated information including such items as patient's name, sex, age, admission date, discharge date, status upon discharge, medical record number, attending physician and surgeon and any other required demographic information and records on abstract worksheet.

2. Reviews patients' current emergency treatment record and assigns appropriate code(s) and physician billing component(s) using the International Classification of Disease system and Current Procedural Terminology guidelines.

3. Determines the sequence of diagnoses according to uniform hospital discharge data.

4. Abstracts information and enters into patient registration system. Verifies physician name(s) and appropriate UCC charges based on nursing acuity. Makes corrections as necessary.

5. Determines whether the emergency department visit was an emergency at time of coding and when insurance status changes on previously billed patients.

6. Requests diagnoses from physicians when not recorded on discharge or if information is incomplete.

7. Prepares and distributes documents such as physician reminder notices, suspension lists, and/or other controlling documents.

8. Checks for missing dictations and notifies appropriate physician of incomplete documentation needed for billing purposes. Ensures documentation is completed. Provides appropriate feedback to Department Directors.

9. Maintains accurate listing of inpatient accounts on hold. Checks daily charge entries and releases billings appropriately.

10. Retrieves elusive records needed for billing prior to closing out the month.




Minimum Education High School or G.E.D.

Minimum Experience 6 - 12 months

Req Cert/Registration Registered Health Information Technician (RHIT) or Medical Secretary

Preferred Course Training College level course in medical terminology; coursework in anatomy and physiology

Skills: Other Knowledge of ICD-9-CM and/or CPT-4 coding; basic computer skill

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