Medical Coder Inpatient Coding
Medical Coder Inpatient Coding
Posted on :
22-10-2024
Employer Active
1 Vacancy
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Monthly Salary
Not Disclosed
Salary Not Disclosed
Vacancy
1 Vacancy
Posted on :
22-10-2024
Job Description
JOB SUMMARY: Under the general supervision of the Operations Manager the Coder assigns diagnosis 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 outpatient or physician/ professional coding but must be able to code all patient types depending on business requirement. Appropriately code for International Classification of Diseases 10th Revision Clinical Modification (ICD10CM)/diagnosis and Procedure Codes such as Current Procedural Terminology (CPT) International Classification of Diseases 10th Revision Procedure Coding System (ICD10PCS) or Healthcare Common Procedure Coding System (HCPCS). related to a patient s admission in order to provide billing and statistical information. The work of this position is guided by defined policies guidelines and established practices and precedents. The method of chart analysis normally required to solve problems or make decisions is to collect compile and organize facts figures and/or other information in accordance with established procedures or as directed by facility policy. This position is responsible to adhere to all federal guidelines as set forth by CMS and State guidelines and as per coding rules and guidelines set in the AHA Coding Clinics. The Medical Coder must be able to meet a minimum of 95% quality and productivity target set by the organization or by the client. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Abstracts codes and sequences the classification of medical and surgical procedures diagnosis and treatment modalities on Inpatient and Day Surgeries. 2. Reviews appropriate provider documentation to determine principal diagnosis comorbidities and complications secondary conditions and surgical procedures. 3. Selects the latest most accurate and descriptive codes per specialty: a. For Inpatient specialty i. ICD10CM for diagnosis coding ICD10PCS for procedure coding ii. Assigns Present on Admission (POA) value for inpatient diagnoses as a supplement for ICD10CM coding. iii. Assigns correct Principal Diagnosis Secondary Diagnosis especially that are Comorbid Complication (CC) and/or Major Comorbid Complication (MCC) iv. Assigns correct DiagnosisRelated Grouping (DRG) and perform coding compliance reviews. Follow official coding guidelines to review and analyze health records. b. For Outpatient and Professional specialties i. ICD10CM for diagnosis coding CPT for procedure coding and any applicable HCPCS coding ii. Assigns correct Ambulatory Payment Classification (APC) for facility and perform coding compliance reviews. Follow official coding guidelines to review and analyze health records. iii. Follows specific guidelines and instructions from the facility payer and physician. 4. Writes a compliant query to the provider for documentation and coding improvement. 5. Enters codes into computer system extract required information from source documentation and enter data into encoder and abstracting system. 6. Reports to their supervisor their productivity status and daily issues. 7. Identifies and reports areas of concern with respect to improper coding and documentation. 8. Maintains confidentiality of patient records at all times.
Employment Type
Full Time
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