Medical Coder

Job Description

• Review and assign accurate ICD-9/ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information.

• Ensure that final diagnoses and operative procedures documented by physicians are valid, complete, and appropriately coded.

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

• Evaluate medical records for consistency and adequacy of documentation, ensuring accurate reflection of care and treatment provided.

• Compute and assign correct Diagnosis-Related Groups (DRGs) for all inpatient cases.

• Provide training and guidance to other coders and Medical Records Technicians, including updates on new coding guidelines, rules, and regulatory changes.

• Analyze physician documentation to ensure accurate assignment of Evaluation and Management (E&M) levels using appropriate CPT codes.

• Ensure all coding is performed in accordance with HAAD (or relevant local health authority) guidelines and regulations.

• Provide feedback to physicians regarding coding errors, omissions, or discrepancies.

• Maintain up-to-date knowledge of the latest coding versions and HAAD directives.