IP Medical Coder

Job Description

• Checks and sequences the most accurate ICD-9/ICD-10-CM/CPT/HCPCS/DRG/other codes for diagnoses and procedures based on documented information, ensuring final diagnoses and operative procedures stated by the physician are valid and complete.

• Abstracts necessary information from health records to identify secondary complications and co-morbid conditions.

• Evaluates records for documentation consistency and adequacy; ensures the final diagnosis reflects the care provided; computes and assigns the correct DRG for all inpatient cases.

• Provides training and guidance to other coders/medical records technicians, including updates on new coding rules and regulations.

• Analyzes physicians’ documentation to ensure appropriate E&M levels and correct CPT codes are assigned.

• Ensures coding compliance with HAAD guidelines and regulations.

• Provides feedback to doctors regarding coding errors or oversights.

• Keeps updated with the latest coding versions and HAAD coding directives.

• Performs miscellaneous job-related duties as assigned.

• Performs any other tasks assigned by the HOD within the scope of the job title.

• Complies with all OSH and infection control policies, standards, and procedures; cooperates with hospital management to meet compliance requirements.

• Works in accordance with documented OSH procedures and instructions.

• Is familiar with emergency and evacuation procedures.

• Reports OSH hazards, incidents, near misses, and assists with risk assessments and incident reports.

• Complies with waste-management procedures and policies.

• Attends applicable OSH/Infection Control training programs, mock drills, and awareness programs.

• Uses appropriate personal protective equipment (PPE) and safety systems as required.