Clinical Coder - General Radiology
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Key skills for this role
About the Role
Sheikh Shakhbout Medical City is seeking a Clinical Coder to review, analyze, and code medical records using ICD-10-CM and CPT codes. The role involves ensuring accurate coding, collaborating with CDI and physicians, and maintaining productivity targets.
Key Skills for This Role
Responsibilities
- Review, analyze, and code documentation for hospital medical records using ICD 10 CM and CPT
- Assign codes for diagnoses, treatments, and procedures for complex inpatient, outpatient, ED, or observation encounters
- Ensure accurate coding by clarifying diagnosis and procedural information through a query process
- Assign Present on Admission (POA) value for inpatient diagnoses
- Maintain assigned target of production and accuracy of coding
- Collaborate with CDI, physicians, and Revenue Cycle Management teams
- Prepare statistics as requested by management
Requirements
- Experience in medical coding with ICD 10 CM and CPT
- Knowledge of official coding guidelines and ethical coding standards
- Ability to code multiple specialties
- Strong attention to detail and accuracy
- Ability to mentor and train other coding levels
Full Job Posting
Job Summary
- The Clinical Coder reviews, analyzes, and codes documentation for hospital medical records to select and sequence the appropriate ICD 10 CM diagnosis, CPT procedure codes as applicable.
- This position is responsible for the accurate assignment; abstracting to determine accuracy and completeness of the record, utilizing the 3M Coding Reimbursement to compile data and related work assigned.
- Coding staff in this position are able to code encounters of multiple specialties, as well as mentor and train other coding levels.
Responsibilities
- Consults reference materials to facilitate code assignment.
- Validates charges by comparing charges with health record documentation as necessary.
- Understands appropriate link of diagnosis to procedure when applicable.
- Utilizes retrospective edit tool to address possible coding and/or documentation issues.
- Consults with CDI, physicians, or other healthcare providers when additional information is needed.
- Collaborates with Revenue Cycle Management teams in resolving billing and utilization issues.
- Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters, outpatient (OP)/emergency department (ED) or observation short stay.
- Prepares and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures and E&Ms.
- Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.
- Ensures accurate coding by clarifying diagnosis and procedural information through a query process.
- Assigns Present on Admission (POA) value for inpatient diagnoses.
- Assigns an accurate physician name against each service and accurate time and date.
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