Duke Homecare & Hospice offers hospice, home health and infusion services. Hospice care is offered to terminally ill patients in their home, skilled-nursing facilities, assisted-living facilities, and at our two inpatient facilities located in Hillsborough and Durham, North Carolina.
General Description of the Job Class The Duke HomeCare &Hospice Medical Records Coder II is a certified Coder, responsible for coding activities for the home health and hospice areas at Duke. Code medical records utilizing ICD-10-CM and CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures.
Duties and Responsibilities of this Level
Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions.
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions. Sequence the diagnoses and procedures using coding guidelines. Ensure DRG (Diagnostic Related Grouping) /APC (Medicare's Ambulatory Payment Classification) assignment is accurate. Abstract and compile data from medical records for appropriate optimal reimbursement for Home Health or Hospice and/or professional charges.
Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
Maintain a thorough understanding of medical record practices, standards, regulations, The Joint Commission, Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), DHHS (Department of Health and Human Service), etc.
Assist with special projects as required.
Perform other related duties incidental to the work described herein.
Required Qualifications at this Level
Education High school diploma required
Prior experience in homecare and hospice coding strongly preferred
RHIA certification- no experience required
RHIT certification- no experience required
CCS certification- one year of coding experience required
CPC or HCS-D certification- two years of coding experience required
Degrees, Licensure, and/or Certification
Must hold one of the following active/current certifications:
Registered Health Information Administrator (RHIA) Hospital Coding
Registered Health Information Technician (RHIT) Hospital Coding
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
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