Medical Record and Health Information Technician/Medical Coders

Urban Institute

National (OA)

National Occupational Frameworks

Documents

Individual state requirements may vary. Please contact your local apprenticeship office to ensure this version is suitable to your state’s requirements.

Work Process Schedule

Work Process Content

On the Job Training

Anonymous

Skills

Properly applies diagnosis and procedure codes to medical charts, records and related documents

Enters or confirms code(s) associated with medical diagnosis(es), procedures, and services
Ensures medical codes reflect medical record documentation

Supports documentation of care for services provider reimbursement process to ensure timely and accurate payment

Ensures accuracy of diagnosis/procedural groups such as DRG (Diagnosis Related Group), MSDRG (Medical Severity), APC (Ambulatory Payment Classification), etc.
Communicates with physicians or other care providers to ensure appropriate documentation
Applies policies and procedures to comply with changing regulations among various payment systems for healthcare services, such as Medicare, Medicaid, managed care, etc.
Applies policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery
Supports accurate billing through coding, charge master, claims management and bill reconciliation processes
Ensures accuracy of diagnostic/procedural groupings such as DRG and APC
Resolves discrepancies between coded data and suppoRIng documentation

Maintains accurate and complete patient health records

Compiles patient data and performs data quality reviews to validate code assignment and compliance with repoRIng requirements
Ensures that medical records are complete, including medical history, care or treatment plans, tests ordered, test results, diagnosis and medications taken
Verifies consistency between diagnosis and treatment plans, procedures and services

Ensures compliance with healthcare law, regulations and standards related to information protection, privacy, security and confidentiality

Participates in compliance (fraud and abuse), HIPAA (Health Insurance Portability and Accountability Act of 1996), and other organization specific training
Validates coding accuracy using clinical information found in the health record
Adheres to current regulations and establish guidelines in code assignment (focus on assignment of principle diagnosis, principle procedure, and sequencing as well as other clinical coding guidelines
Uses established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative and others

Maintains appropriate technology solutions including health information systems to support health care delivery and organizational priorities

Specifies, refines, updates, produces and makes available a formal approach to implement information and communication technology solutions necessary to develop and operate the health information system architecture in support of the organization
Stays apprised of innovative solutions for integration of new technology into existing products, applications or services
Identifies and clarifies user needs (internal and external customers) and organizational policies to ensure system architecture and applications are in line with business requirements
Uses and maintains applications and processes to support other clinical classification and nomenclature as appropriate (e.g. DSM-V - Diagnostic and Statistical manual of Mental Disorders - SNOMED-CT - Systemized Nomenclature of Medicine -Clinical terms, etc.)

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