What are the responsibilities and job description for the MEDICAL ABSTRACTIONIST - PHYSICIAN PRACTICE position at Becker Health?
Reviews and interprets the documentation of physician services in patient records to report physician activity for professional services billing. Key components of the reporting of physician services include coding of services using CPT-4 service codes and ICD-10 diagnoses codes. Must apply Departmental standards for the documentation and reporting of physician services in determining the correct level of service supported by the documentation of physician services in the patient record.
1. Systematically review and analyze patient records to determine the principal diagnosis and level of service, all significant additional diagnoses and procedures and to produce a coded abstract for physician billing (60%)
- Review up to 90 patient charts per day and abstract diagnoses, physician services and procedures with 95% accuracy, 100% of the time.
- Abstract charts of patients no longer under care of practice physicians within two working days of discharge from care, 90% of the time.
2. Code diagnoses, level of service and procedures consistent with patient care documentation (20%)
3. Serve as a resource to Department physicians regarding guidelines for patient care documentation and respond to physician inquiries on proper documentation of patient care (10%)
4. Maintain a thorough knowledge of current diagnosis and procedural coding practices and their application to the scope of services provided by Department physicians (10%)
Maintain certification as a procedural coder.
