IP Medical Coder
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Key skills for this role
About the Role
Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations. Responsibilities Assigns accurate ICD-9 / ICD-10-CM / CPT / HCPCS / DRG c.
Key Skills for This Role
Responsibilities
- Assign accurate ICD 9/ICD 10 CM/CPT/HCPCS/DRG codes for diagnoses and procedures
- Ensure final diagnoses and operative procedures documented by physicians are valid and complete
- Abstract relevant information from health records to identify secondary complications and co morbidities
- Review medical records for documentation consistency and adequacy
- Compute and assign correct DRG coding for all inpatient cases
- Provide training and guidance to coders and Medical Records Technicians
- Analyze physician documentation to ensure correct E&M level assignment using CPT codes
- Ensure coding compliance with HAAD guidelines and regulatory requirements
- Provide constructive feedback to physicians on coding discrepancies
- Comply with OSH and infection control policies and procedures
Requirements
- Knowledge of ICD 9/ICD 10 CM, CPT, HCPCS, and DRG coding systems
- Ability to abstract relevant information from health records
- Familiarity with HAAD coding guidelines and regulatory requirements
- Experience in providing training and guidance to coders
- Compliance with OSH and infection control policies
Full Job Posting
Job Overview
- Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.
Responsibilities
- Assigns accurate ICD 9 / ICD 10 CM / CPT / HCPCS / DRG codes for diagnoses and procedures based on documented clinical information.
- Ensures final diagnoses and operative procedures documented by physicians are valid and complete.
- Abstracts relevant information from health records to identify secondary complications and co morbidities.
- Reviews medical records for documentation consistency and adequacy, ensuring diagnoses reflect the care provided.
- Computes and assigns correct DRG coding for all inpatient cases.
- Provides training and guidance to coders and Medical Records Technicians, including updates on coding standards and regulations.
- Analyzes physician documentation to ensure correct Evaluation & Management (E&M) level assignment using appropriate CPT codes.
- Ensures coding compliance with HAAD guidelines and regulatory requirements.
- Provides constructive feedback to physicians on coding discrepancies or documentation gaps.
- Keeps up to date with the latest coding systems, versions, and HAAD directives.
- Performs additional job related duties as assigned.
- Undertakes any other responsibilities assigned by the Head of Department (HOD) within the job scope.
OSH & Compliance Responsibilities
- Complies with all Occupational Safety & Health (OSH) and infection control policies and procedures.
- Works in accordance with established OSH procedures and responsibilities.
- Maintains familiarity with emergency and evacuation procedures.
- Reports hazards, incidents, and near misses, and assists in risk assessments and incident reporting.
- Adheres to waste management policies and procedures.
- Participates in OSH and infection control training, mock drills, and awareness programs.
- Utilizes appropriate personal protective equipment (PPE) and safety systems.
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