Under the general supervision of the Operations Manager, the Coder assigns diagnostic and procedure codes to patient medical records and enters coding and abstracting patient data into the facility computer system. Generally, performs coding on all types of cases. Position can be specialized to code inpatient or outpatient coding, but must be able to code all patient types. Coding all ICD-9-CM, CPT-4, Diagnosis and Procedure Codes related to a patient's admission in order to provide billing and statistical information.
Experience Needed: Requires a minimum of 6 months Hard Coding experience. A working knowledge of Inpatient and Outpatient coding requirements.
Certification/licensure: Must have current Certification as Certified Medical Coder such as; CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CCS (Certified Coding Specialists), and COC (Certified Outpatient Coder)
JOB RESPONSIBILITIES:
- Abstracts, codes, and sequences the classification of medical and surgical procedures, diagnosis, and treatment modalities on Inpatient and Day Surgeries.
- Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions, and surgical procedures.
- Selects the latest, most accurate and descriptive codes from the listings of International Classification of Diseases, Clinical Modification (ICD- CM), American Medical Association Current Procedural Terminology (CPT-4) coding system, and Healthcare Common Procedure Coding System (HCPCS).
- Assigns Present on Admission (POA) value for inpatient diagnoses as a supplement for ICD-9 CM coding.
- Assigns correct diagnostic related grouping (DRG) and perform coding compliance reviews. Follow official coding guidelines to review and analyze health records.
- Enters codes into computer system, extract required information from source documentation and enter data into encoder and abstracting system.
- Reports to their supervisor their productivity status and daily issues.
- Identifies and reports areas of concern with respect to improper coding and documentation.
- Maintains confidentiality of patient records at all times.
