IP Medical Coder

Job Description

• The incumbent checks and sequences the most accurate ICD-9/ ICD10-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.

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

• Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Computes and gives the correct DRG coding all inpatient cases.

• Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

• Analyzes doctors’ documentation to assure the appropriate Evaluation & Management (E&M) levels are assigned using the correct CPT code.

• Ensures coding is as per DOH guidelines and regulations.

• Provides feedback to Doctors regarding coding errors or oversights.

• Constantly updates to the latest coding versions and DOH coding directives.

• Performs miscellaneous job-related duties as assigned.

• Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

• Follow security and privacy policies and procedures for the use of networks, including intranet and internet.

• Follow confidentiality and security measures to protect electronic health information.

• Maintain data integrity and validity within an information system.

• Report any possible breaches of confidentiality in accordance with organizational policies.