Codes and abstracts reportable diseases, procedures and state regulatory data elements from the medical record according to ICD-CM/PCS and CPT classification systems, state and national regulatory agencies respectively. Validates coding to assure proper DRG/SOI/ROM/APC assignment. Participates in quality improvement activities and communicates with physicians, CDI and IP Rehab Coordinators concerning incomplete documentation and clarification of diagnoses/procedures.
Requirements
- Codes and abstracts reportable diseases, procedures and state regulatory data elements from the medical record according to ICD-CM/PCS and CPT classification systems, state and national regulatory agencies respectively
- Validates coding to assure proper DRG/SOI/ROM/APC assignment
- Communicates with physicians, CDI and IP Rehab Coordinators concerning incomplete documentation and clarification of diagnoses/procedures
- Participates in quality improvement activities
