Job Summary:

The PAS Coder and Abstractor will abstract and code ICD-9-CM required by CPHA Type II abstracts from dismissed patients medical records according to CPHA procedures and standards and the needs of the medical records department, the administration, and medical staff.

Supervisory Responsibilities:

• None.

Duties/Responsibilities:

• Abstracts in detail and completes case abstract from patients medical records. Codes (ICD-9-CM or CPT-4) patient records for indexing operations, diagnoses, and physicians' and surgeons' planning reports. Organizes work for accuracy and effectiveness of reporting system. Audits monthly reports for correctness to ensure accuracy of semiannual and annual reports and indexes.
• Reports to the infection control officer possible nosocomial infections identified at the time of coding and abstracting.
• Reports to the quality assurance coordinator unusual occurrence snot accompanied by a report from the nursing department.
• Identifies cases for tissue review at the time of coding and abstracting and prepares the monthly tissue review worksheet for the surgery committee.
• Gives advice on the selection of optional areas for new abstract items desired. Reports deficiencies found during chart reviews and abstracting. Reviews and aids with the monthly reporting system and in special studies or audits for committees, etc. Sets up the report format on Meditech for monthly abstracting statistics.
• Performs daily, monthly, and yearly departmental statistical reviews.
• Attends training sessions to maintain knowledge and expertise.
• Reports coding problems to the medical records assistant director after evaluation and/or coding using the consulting service of the CHPA. Assembles and checks charts for deficiencies. Rechecks charts after physicians complete them.
• Maintains an ongoing surveillance of the abbreviations in use and submits new abbreviations to the medical records director for possible approval.
• Trains employees for backup when requested.

Required Skills/Abilities:

• Thorough knowledge of classification and nomenclature, anatomy, medical terminology, and medical records procedures and practices.
• Understanding of ICD-9-CM and CPT-4.

Education and Experience:

• High school diploma or equivalent

Physical Requirements:

• Work is sedentary in nature; however, the ability to stand and/or walk for periods of three hours or more and examine or manipulate objects at high or low reach is required.
• The position requires some pulling, filing, and copying of charts.
• Work is repetitive and monotonous in nature and requires concentration and constant technical attention to accuracy and detail for extended periods of time.