POSITION SUMMARY: This position is located in the Health Information Department of the Owyhee Community Health Facility, Owyhee, Nevada. The position is responsible for processing electronic health records (EHR): transcribing and encoding patient health information. The medical coding reflects on a variety of health-related information for each patient visit, i.e., provider seen, personal and family history, laboratory test results, diagnosis, treatment and medications prescribed. MAJOR DUTIES AND RESPONSIBILITIES: 1. EHR Visit Examination: Examines patient visit records for accuracy and completeness. Checks for required patient data. Notifies appropriate provider, through E.H.R. notification function, of incomplete/inaccurate visits that need correction or clarification. Provide explanations to the provider as necessary. 2. Encounter Record Visit Coding: All visit diagnoses and procedures are transcribed into codes. The codes are assigned using the current ICD-10-CM, CPT, and HCPCS coding classification systems. Code selection involves deciphering between diagnoses, treatment or therapy and includes special codes to denote causes of illness, accident/injury, adverse effects, etc. The incumbent will exercise the final responsibility to the completion of coding all diagnoses and procedures, before the data entry phase. 3. Data Entry: Patient medical information is abstracted and data entered from various source documents such as progress notes, operative reports and medical documents created by other Physicians. Pertinent data will be appended to existing visits utilizing the data entry mnemonics. Pertinent medical data will result in a tool useful to health care providers and administrators. 4. Visit Merge: Determines and performs patient encounter visit merging. Merges orphaned visits with primary visit. 5. Statistical Audits: Performs periodic audits of the coding and data entry process for the purpose of establishing reports on total productivity including the time between patient visit and when it is recorded into the EHR system, degree of accuracy of the data, and the total volume of patient visits entered during a given period of time. 6. Error Reports: Error reports are generated bi-monthly to ensure completed coding and data entry of all orphaned encounter visits, before exporting data to data warehouse for local/state/federal statistical reporting. 7. In-service Training: Will provide training to the Medical Staff/Nursing Staff/Health Information Services Staff of Evaluation and Management (E/M) documentation for assigning accurate codes, which will facilitate accurate documentation and accurate billing. 8. Will keep abreast of the changes of the documentation requirements, of the national regulatory agency, and will maintain compliance of these issues. 9. Will be available as an expert resource for data entry queries, coding and compliance issues. 10. Other Duties: Performs other related duties as assigned by supervisor. MINIMUM QUALIFICATIONS AND KNOWLEDGE REQUIRED BY THE POSITION: Grade 19 – Must have current and up-to-date- knowledge, in all areas listed below, to enable the candidate to successfully complete the coding program and receive certification within 1 (one) year in medical coding, 6 months experience in medical related field highly recommended. Grade 22 – Must be a certified medical coder and must have knowledge in all areas listed below and currently have 1 (one) year of experience in medical coding and/or billing. 1. Must have a High School Diploma or G.E.D and medical coding experience. 2. Knowledge of medical terminology and usages, physiology, major anatomical system and related disease processes of each in order to examine EHR Progress Notes and or Patient Care Component forms to ensure proper codes, monitors coding to identify discrepancies involving deciphering between diagnoses, treatment or therapy, causes of illness, accident/injury, and adverse affects. 3. Have knowledge of health record forms and templates, and the legal and regulatory requirements of medical records to insure that the record is acceptable as a legal document. 4. Knowledge of the most common coding systems and references utilized in the Health Information Services for the classifications of diseases and procedures. Coding systems and pertinent references are the International Classification of Diseases ICD-10-CM Current Procedural Terminology IV (CPT)/HCPCS coding manuals, medical dictionaries, etc. 5. Knowledge of (HIPAA) Health Insurance Portability Accountability Act, which governs all health information and transaction code sets, nationally; and in conjunction with HIPAA is the Privacy Act1974 and freedom of Information Act. 6. Must have knowledge of data collection methods for basic health care and research information within scope of duties. 7. Must have knowledge of computerized data entry skills and information processing systems. 8. Must have the skill of a qualified typist to operate a keyboard or use a modified keyboard. 9. The skill to verbally converse with health care professionals and others to discuss documentation requirements for a variety of forms. SUPERVISORY CONTROLS: The Health Information Manager or designee makes initial assignments, relying on judgment of the incumbent to select the procedures to be followed and the medical references to be used. The incumbent is responsible for the timeliness of work and works largely on own initiative in applying the methods, procedures and techniques used. The supervisor is consulted only on unusual problems for which no precedent or reference is available. The completed work and the methods used are checked for technical accuracy and compliance with instructions and established procedures. GUIDELINES: Guidelines are generally verbal, and are supplemented by printed format layouts, coding tables and minimal outlines of procedures. The employee must exercise judgment in selecting and adapting guidelines to assure timeliness, continuity, and accuracy in the relationships between data acquisition, coding, data entry and file maintenance. Problems, which may occur and are not covered by established methods and procedures, may be referred to the department supervisor. COMPLEXITY: The work requires consideration of a variety of detailed and interrelated information and procedures to accomplish control, coding, abstracting, data entry and modification. Considerable decision-making is required of the employee. The duties of this position comprise a portion of one large, complex data system. A good general understanding of the overall system, and the interaction of the employee’s role within the broader context are necessary for effective execution of the duties. SCOPE & EFFECT: The patient identification, coding, data acquisition, data entry and management reports distribution and control functions are all critical to the smooth operation of a data processing department essential to the management of health delivery service of the Indian Health Service. The work directly affects the accuracy, timeliness, and reliability of major components of the system involved. PERSONAL CONTACTS: Contacts are with health professionals and other coding and data entry personnel as well as routine telephone contacts with RPMS and EHR system users. PURPOSE OF PERSONAL CONTACTS: Contacts with peers and health professionals are for obtaining/verifying data utilized in the completion of the Patient Encounter to determine patient’s purpose of visit, signatures required on progress notes, dates and time of visits, etc., before submitting reports. PHYSICAL DEMANDS: There is nominal standing, working between equipment and similar movement around the immediate environment in addition to carrying up to 5 pounds of reports for shredding. There are long periods of work at a computer terminal retrieving data from the RPMS database. WORK ENVIRONMENT: The majority of the work is performed in an office setting, which is generally well lighted, has adequate ventilation and temperature control and poses no unusual risks or discomforts. Operation of a shredding machine is performed to accomplish the proper disposal of confidential data. Safety precautions required on the job are those normally applicable to such an environment
