Med Abstraction - Intensive Care

Job Summary

Reviews and interprets the documentation of physician services in patient records to report physician activity for professional services billing.  Key components of the reporting of physician services include coding of services using CPT-4 service codes and ICD-10 diagnoses codes.  Must apply Departmental standards for the documentation and reporting of physician services in determining the correct level of service supported by the documentation of physician services in the patient record.

Job Responsibilities

1. Systematically review and analyze patient records to determine the principal diagnosis and level of service, all significant additional diagnoses and procedures and to produce a coded abstract for physician billing (60%)

• Review up to 90 patient charts per day and abstract diagnoses, physician services and procedures with 95% accuracy, 100% of the time.
• Abstract charts of patients no longer under care of practice physicians within two working days of discharge from care, 90% of the time.

2. Code diagnoses, level of service and procedures consistent with patient care documentation (20%)

• Complete ICD-10 and CPT-4 coding with 95% accuracy, 100% of the time.

3. Serve as a resource to Department physicians regarding guidelines for patient care documentation and respond to physician inquiries on proper documentation of patient care (10%)

• Complete a Documentation Problem Sheet within four hours of identification of a problem/issue, 90% of the time.
• Respond to physician inquiries within two hours with recommendations and/or options for problem resolution, 90% of the time.

4. Maintain a thorough knowledge of current diagnosis and procedural coding practices and their application to the scope of services provided by Department physicians (10%)   -Maintain certification as a procedural coder.

Job Responsibilities (Continued)

Required Licenses, Certifications, Registrations

AAPC, AHIMA, or CCS (Physician based (AHIMA)

Required Education and Experience

Required Education: High school diploma / GED

Required Experience: One (1) year of coding experience

Preferred Education, Experience & Cert/Lic

Preferred Education: Associates degree

Preferred Experience: Two (2) or more years of coding experience

Preferred Experience: Epic 

Additional Technical Requirements

• Ability to read and analyze medical records.
• Clear oral and written communication skills.
• Professional telephone etiquette.
• Ability to interact with physicians and patients’ parents or guardians in a professional and helpful manner.
• Ability to use PC skillfully.  Knowledge of EPIC preferred.
• Ability to work independently.
• Problem-solving and decision-making skills.