Mount Nittany Health

Medical Billing and Coding

• Codes outpatient and emergency room charts.
• Analyzes and searches the documentation listed in the entire medical record for all documented clinical information (diagnoses and procedures) in accordance with established procedures, daily, for the Emergency Room and Outpatient Clinic.
• Maintains standard coding accuracy rate of 95% according to the National Standard Coding Accuracy Rate.
• Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.
• Enters accurate ICD-10 and CPT-4 codes, physician related and clinical information, and demographic information into computerized coding/abstracting system, in accordance with established procedures, maintaining a 95% accuracy rate, on a daily basis.
• Performs insurance billing activities.
• Coordinates outpatient coding for Medicare, Blue Cross, Medical Assistance, HMO’s, and Commercial Insurance accounts.
• Maintains timely completion of records.
• Remains current in coding rules and practices.

ED Clinical Coding Specialist, Certified

• The responsibility of the Coding Specialist Certified is to search a patient's entire medical record to ensure comprehensive coding and abstracting utilizing the coding rules, principles and ethics under the supervision of the Coding Supervisor and Manager, Health Information Management.
• With quality and reimbursement contingent upon coding, it is the responsibility of the Medical Center Coding Specialist Certified to have knowledge of DRG methodology, ICD-10, CPT-4 and APC coding rules and principles.
• Reviews the medical record for diagnoses and procedures performed.
• Analyzes and searches the documentation listed in the entire medical record for all documented clinical information (diagnoses and procedures) in accordance with established procedures, daily, and trained in a minimum of 3 out of the 4 following areas: Inpatient records, Outpatient records, Emergency Room records, Clinical /Diagnostic records.
• Identifies and sequences principal diagnosis, secondary diagnoses, principal procedures, complications and comorbid conditions, for optimal reimbursement, utilizing proper coding practices, on a daily basis.
• Selects ICD 10-, CPT-4, DRG code assignments.
• Assigns proper ICD-10, CPT-4, DRG codes for all diagnoses, procedures, complications, and comorbid conditions during the course of hospitalization after researching the entire record, maintaining a 95% accuracy rate, on a daily basis.
• Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.