Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.
Responsibilities:
Checks and sequences the most accurate ICD-9/ICD-10-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures. Ensures final diagnoses and operative procedures stated by the physician are valid and complete.
Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
Evaluates records for documentation consistency and adequacy. Ensures the final diagnosis accurately reflects the care and treatment rendered and computes correct DRG coding for all inpatient cases.
Provides training and guidance to other coders / Medical Records Technicians, updating them with new coding rules and regulations as necessary.
Analyzes doctors’ documentation to ensure appropriate Evaluation & Management (E&M) levels are assigned using the correct CPT code.
Ensures coding complies 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 jobs or duties assigned by the HOD within the scope of the job title.
Complies with all OSH and infection control policies, standards, and procedures, cooperating with hospital management to meet requirements.
Works in accordance with documented OSH procedures and instructions, fulfilling specific responsibilities.
Familiar with emergency and evacuation procedures.
Notifies OSH hazards, incidents, near misses, and issues; assists with preparation of 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 and safety systems.
Qualifications: