Medical Coder  

The Medical 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-10, ICD-9-CM, CPT-4, Diagnosis and Procedure Codes related to a patient’s admission in order to provide billing and statistical information.

ESSENTIAL FUNCTIONS:

• Analyze patient charts carefully to know the diagnosis and represent every item with specific codes
• Collect health information as documented by medical specialists and code them appropriately
• 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 or ICD-10 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.
• Consult medical specialists for further clarification and understanding of items on patient charts to avoid any misinterpretations
• Ensure that codes tally with doctors’ diagnosis
• 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.
• Evaluate and re-file appeals of patient claims that were denied
• Develop good client relationship in the course of duty
• Collect and distribute coding related information and billing issues
• Provide accurate answers to queries on coding

Qualifications:

Graduates of Medical Allied Course

With Certification preferred (license should be up to date)

With 1-2 years experience as Medical Coder

Knowledge and Skills:

Must have an expert understanding of computer applications. Must be able to adapt and learn coding guidelines and medical terminology. Requires expert knowledge of automated encoder system. Must have the analytical ability necessary to interpret data contained in records and to assign appropriate codes and the visual acuity necessary to read and decipher handwriting. Must be able to learn ICD9, ICD10 coding systems and MS Diagnostic-Related Groups and APC’s. Must be able to communicate effectively and have excellent customer service skills. Requires the ability to read, write and speak effectively in English.