Under general supervision, the coder assigns diagnostic and procedural codes to patient charts of moderate to high complexity levels using ICD-10-CM, CPT & PCS and any other designated coding classification system in accordance with coding rules and regulations. Inpatient DRG coding experience in trauma care, long term / short term hospitals is a must.
• Reviews medical records for the determination and accurate assignment of all documented diagnoses and procedures.
• Assigns and sequence codes based on medical record documentation.
• Assigns appropriate discharge disposition Abstracts and enters coded data and designated quality management data for hospital statistical and reporting requirements.
• Communicates documentation improvement opportunities and coding issues (i.e., discrepancies, physician queries, etc.) to the appropriate personnel for follow up and resolution.
• Must have knowledge in clinical indicators & disease process.