Electronic Health Record Coder
Electronic Health Record Coder
Title: Electronic Health Record Coder
As a medical coder you will be responsible for reviewing patient documentation for encounters that has been added to an Electronic Health Record by a provider. You will ensure the accuracy and integrity of the codes that are used. Additionally, you will review each medical record for compliance purposes and report issues that may be apparent. When there is a question, you will ask or query your provider to confirm that the medical record supports the code selection. It really begins with the medical coder as they are the gatekeepers or coding accuracy and complian
Include the following aspects in the assignment:
· Describe what you feel a day may be like once you become a coder
· What do you think will be most challenging?
· Summarize why it is essential to collaborate with clinical staff (MDs/APRNs) to resolve coding questions/discrepancies· Provide an example of a time when it may be necessary to query a physician.
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A (4) | B (3) | C (2) | D/F (1/0) | |
Focus: Purpose | Purpose is clear | Shows awareness of purpose | Shows limited awareness of purpose | No awareness |
Main idea | Clearly presents a | There is a main idea | Vague sense of a | No main idea |
main idea and | supported throughout | main idea, weakly | ||
supports it | most of the paper. | supported | ||
throughout the | throughout the | |||
paper. | paper. | |||
Organization: | Well-planned and | Good overall | There is a sense of | No sense of |
Overall | well-thought out. | organization, includes | organization, | organization |
Includes title, | the main | although some of the | ||
introduction, | organizational tools. | organizational tools | ||
statement of main | are used weakly or | |||
idea, transitions and | missing | |||
conclusion. | ||||
Organization: | All paragraphs have | Most paragraphs have | Some paragraphs | Para. lack clear ideas |
Paragraphs | clear ideas, are | clear ideas, are | have clear ideas, | |
supported with | supported with some | support from | ||
examples and have | examples and have | examples may be | ||
smooth transitions. | transitions. | missing and | ||
transitions are weak. | ||||
Content | Exceptionally well- | Well-presented and | Content is sound and | Content is not sound |
presented and | argued; ideas are | solid; ideas are | ||
argued; ideas are | detailed, developed | present but not | ||
detailed, well- | and supported with | particularly | ||
developed, | evidence and details, | developed or | ||
supported with | mostly specific. | supported; some | ||
specific evidence & | evidence, but | |||
facts, as well as | usually of a | |||
examples and | generalized nature. | |||
specific details. | ||||
Research (if | Sources are | Sources are well | Sources support | The paper does not |
assignment | exceptionally well- | integrated and | some claims made in | use adequate |
includes a | integrated and they | support the paper’s | the paper, but might | research or if it does, |
research | support claims | claims. There may be | not be integrated | the sources are not |
component) | argued in the paper | occasional errors, but | well within the | integrated well. |
very effectively. | the sources and | paper’s argument. | They are not cited | |
Quotations and | Works Cited conform | There may be a few | correctly according | |
Works Cited | to MLA style sheet. | errors in MLA | to MLA style, nor | |
conform to MLA | style.. | listed correctly on | ||
style sheet. | the Works Cited | |||
page. | ||||
Style: Sentence | Sentences are clear | Sentences are clear | Sentences are | Sentences aren’t |
structure | and varied in | but may lack | generally clear but | clear |
pattern, from simple | variation; a few may | may have awkward | ||
to complex, with | be awkward and there | structure or unclear | ||
excellent use of | may be a few | content; there may | ||
punctuation. | punctuation errors. | be patterns of |
Electronic Health Record CoderElectronic Health Record Coder.