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About This Apprenticeship
The HIM (Health Information Management) Hospital Coder will use coding conventions and guidelines to abstract, analyze, and accurately assign ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) principle and secondary diagnostic and procedural codes to inpatient, ambulatory, and hospital outpatient medical records. The HIM Hospital Coder will query physicians when diagnosis is unclear, audit records, and perform peer reviews. This position must utilize encoder, grouper, and other Health Information Management software often including Electronic Health Records.
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Electronic Health Records Specialist (EHR Specialist)
Health Data Analyst
Health Informatics Specialist
Health Information Administrator
Health Information Clerk
Health Information Coder
Health Information Management Hospital Coder (HIM Hospital Coder)
Health Information Management Technician
Health Information Specialist
Health Information Systems Technician
Health Information Technician (Health Information Tech)
Health Record Technician
Health Services Information Specialist
Health Unit Clerk
Historian
Hospital Unit Clerk
ICD-9 Coder (International Classification of Diseases Coder)
Insurance Coder
Library Historian
Medical Administrative Specialist
Medical Administrative Technician
Medical Biller
Medical Biller Coder
Medical Billing and Coding Specialist
Medical Billing Coder
Medical Billing Specialist
Medical Care Evaluation Specialist
Medical Claims Processor
Medical Coder
Medical Coding Technician
Medical Data Analyst
Medical Insurance Coder
Medical Insurance Coding Specialist
Medical Office Technician
Medical Record Assistant
Medical Record Coder
Medical Record Consultant
Medical Record Specialist
Medical Records Analyst
Medical Records Clerk
Medical Records Coordinator
Medical Records Custodian
Medical Records Director
Medical Records Supervisor
Medical Records Technician (Medical Records Tech)
Medical Reimbursement Specialist
Medical Scribe
Public Health Registrar
Registered Health Information Technician (RHIT)
Release of Information Specialist
Severity of Illness Coordinator
Tumor Registrar
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Software, Tools, or Technology
You may encounter the software, tools, or technology items listed here. They are related to this apprenticeship. Indicates a hot item.
10-key calculators
3M Encoder
Allscripts HER
Amazing Charts
American Medical Association CodeManager
Azalea Health Azalea EHR
Barcode attachment equipment
Barcode scanners
Billing software
Coding database software
ComChart EMR
Computerized indexing systems
Corel WordPerfect
Credit card processing machines
Cyber Records MediChart Express
Data entry software
Desktop computers
Dictaphones
Digital Imaging Communications in Medicine DICOM medical imaging software
DRG grouping software
e-MDs topsChart
eClinicalWorks
EHS CareRevolution
Electronic medical record EMR software
Electronic medical record EMR systems
Email software
eMDs Practice Partner
Encoded archival system EAD
Encoder software
Encoders
EndoSoft
Entity software
Epic Systems
Flat-top scanners
Fox Meadows Accent Data Manager
Fox Meadows ChartingPlus
Fox Meadows EncounterManager
GE Healthcare Logician
Graphics software
Greenway Medical Technologies PrimeChart
Health Care Data HealthProbe
Healthcare common procedure coding system HCPCS
HMS
Holt Systems eMedRec
Hyland Software OnBase
IBM Lotus 1-2-3
IDX Systems IDXtend
IDX Systems Patient Chart Tracking
Information Resource Products Clinical Coding Expert
Label printers
Laser facsimile machines
Laser printers
Laserfiche software
LeonardoMD Renaissance
Light pens
MD Synergy Medical Appointment Scheduling
Mediasoft mediOFFICE
Medical condition coding software
Medical procedure coding software
MedicWare EMR
MEDITECH software
MedStar Systems DrWorks
Microfiche viewing machines
Microfilm viewing machines
Microsoft Access
Microsoft Excel
Microsoft Office
Microsoft Outlook
Microsoft PowerPoint
Microsoft SQL Server Reporting Services
Microsoft Visio
Microsoft Word
Minitab
Multi-line telephone systems
NCG Medical Systems d-Chart
NDCMedisoft
NextGen Healthcare Information Systems EMR
Notebook computers
Optical readers and writers
Paper shredders
PCC EHR
PCC Pediatric Partner
Personal computers
Postal scales
PowerMed
Practice Partner Patient Records
Presentation software
Purkinje Dossier
QMSoftware Receivables Management
SAP Business Objects
SAP Crystal Reports
SAS
Scanners
ScanSoft Naturally Speaking
Scantron imaging software
Scheduling software
Siemens Soarian Financials
Siemens Soarian Scheduling
SOAPware EMR
SoftMed ChartLocater
SoftMed ChartRelease
SoftMed ChartReserve
Speech recognition software
SPSS
STAT! Systems QD Clinical
StataCorp Stata
Switchboards
SynaMed EMR
Tablet computers
Touch screen monitors
Typewriters
VantageMed ChartKeeper
Visionary Medical Systems Visionary OFFICE PM
Voice dictation software
Web browser software
Welford Chart Notes
Word processing software
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Formal Educational Awards
While KnowledgeToWork.com can help you determine which competencies (skills) you will need in this apprenticeship and
locate learning resources to learn those competencies, you may need certain credentials to get a job in this field.
Below is a list of educational institutions and organizations that offer credentials related to AHIMA Hospital/Facility Coder.
Click on the name of the institution or organization for more information.
Knowledge to Work supports other educational goals related to AHIMA Hospital/Facility Coder. You may also be interested in something below. Each have multiple competencies mapped to learning resources.
Health information is the data related to a person's medical history, including symptoms, diagnoses, procedures, and outcomes. Health information records include patient histories, lab results, x-rays, clinical information, and notes. A patient's health information can be viewed individually, to see how a patient's health has changed; it can also be viewed as a part of a larger data set to understand how a population's health has changed and how medical interventions can change health outcomes.
Health information management (HIM) is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. It is a combination of business, science, and information technology.
The Clinical Documentation Improvement Specialist (CDIS) will be responsible for demonstrating competency in coordinating and performing day to day operations, providing concurrent/retrospective review, and improving documentation of all conditions, treatments, and care plans to ensure highest quality care is provided to the patient. In addition, CDIS should be able to educate clinical staff in appropriate documentation criteria. The CDIS will ensure that documentation reflects Medicare Severity Diagnosis Related Groups (MS-DRG), case mix index, severity of illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules. Monitoring changes in laws, rules, regulations, and code assignments that impact documentation and reimbursement is implicit. Knowledge and skills on Microsoft Access database management and ability to present information effectively and clearly is essential.
Medical coders for hospitals spend their days reviewing medical records to assign inpatient and ambulatory surgery codes and ensure that the health care providers they work for are properly reimbursed for their services. Coding accurately is not easy. The coder must carefully read the doctor's and nurse's notes to determine exactly what services the patient received. If a service is overlooked, the provider will not receive payment for it. The coder must also understand private payer policies and government regulations for accurate coding and billing. If the coder chooses the wrong code, the provider may have to return any excess payment or face legal charges for overbilling. Codes change constantly, so coders must keep abreast of new rules and interpretations. A solid understanding of medical terminology, including anatomy, is also required.
The CCPE Technical and Employability Competencies serve as quality indicators of an individual’s readiness to enter an industry or to pursue further education. Competency statements apply to current industry needs, contain both employability skills and technical skills, and leave opportunity for specialized training and career advancement.
Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.
Coding professionals use coding conventions and guidelines to abstract, analyze, and accurately assign International Classification of Diseases, Current Procedural Terminology, and other classification systems, as well as principal and secondary diagnostic and procedural codes to inpatient, ambulatory, and outpatient medical records. Coding professionals also query physicians when diagnosis is unclear, audit records, and perform peer reviews. These professionals use encoder, grouper, and other Health Information Management software, including electronic health records. Job requirements include a current credential, such as Registered Health Information Administrator, Registered Health Information Technician, Certified Coding Associate, or other designated credential from a nationally recognized organization.
Coding professionals assign clinical classification codes for medical services. They also use abstracting databases, internal and external audit results, Quality Improvement Organization reports, and revenue cycle edit and denial information, and they are a resource to the clinical team. This position requires effective interaction with coding staff, clinical staff, and different levels of management throughout the health care system.
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