OP Medical Coder
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Key skills for this role
About the Role
Assign accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation. Validate that final diagnoses and ope.
Key Skills for This Role
Responsibilities
- Assign accurate ICD 9, ICD 10 CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures
- Validate that final diagnoses and operative procedures documented by physicians are complete and compliant
- Abstract relevant clinical information from health records including secondary diagnoses and complications
- Review medical records for documentation consistency, completeness, and adequacy
- Compute and assign the appropriate Diagnosis Related Group (DRG) for all inpatient cases
- Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians
- Ensure coding compliance with applicable HAAD/DOH coding guidelines and regulations
Requirements
- Experience in medical coding with ICD 10, CPT, HCPCS, and DRG
- Knowledge of HAAD/DOH coding guidelines
- Ability to review medical records for documentation consistency
Full Job Posting
Key Responsibilities
- Assign accurate ICD 9, ICD 10 CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
- Validate that final diagnoses and operative procedures documented by physicians are complete, accurate, and compliant with coding standards.
- Abstract relevant clinical information from health records, including secondary diagnoses, complications, and co morbid conditions.
- Review medical records for documentation consistency, completeness, and adequacy to ensure accurate representation of patient care.
- Compute and assign the appropriate Diagnosis Related Group (DRG) for all inpatient cases.
- Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians, including updates on new coding guidelines and regulatory changes.
- Review physician documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.
- Ensure coding compliance with applicable HAAD/DOH coding guidelines, regulations, and organizational policies.
- Provide constructive feedback to physicians regarding coding discrepancies, documentation deficiencies, and missed coding opportunities.
- Stay current with the latest coding classifications, coding updates, and DOH/HAAD coding directives.
Occupational Safety & Health Responsibilities
- Comply with all Occupational Safety & Health (OSH) and Infection Control policies, standards, and procedures.
- Perform duties in accordance with documented OSH policies, procedures, and assigned responsibilities.
- Be familiar with emergency response and evacuation procedures.
- Report OSH hazards, incidents, near misses, and unsafe conditions, and assist in risk assessments and incident investigations.
- Comply with hospital waste management policies and procedures.
- Attend mandatory OSH, Infection Control, safety awareness programs, and emergency/mock drills.
- Use appropriate Personal Protective Equipment (PPE) and follow all applicable safety protocols.
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