Accountable to abstract and code diagnoses and treatment procedures from each discharged patient record, using an international classification of diseases. (ICD/CM). Requires skills in the sequencing of diagnoses/procedures to optimize reimbursement. Ensures that records are coded in an accurate and timely manner. Complies with procedures and standards of the HIM, Medical Staff, and Administration. File records in charts when needed.
- High school diploma or equivalent.
- Medical records training for two to three years with demonstrated knowledge of medical terminology.
- Training as a coder and abstractor.
- Registered Health Information Technician Registered Health Information Administration.
- Thorough knowledge of classification and nomenclature, anatomy, medical terminology, and medical records procedures and practices.
- Understanding of ICD/ CM and CPT
- Within 2 years of hire will obtain CCS/CCSP credentials