The Medical Coder has the primary responsibility recording and interpreting information about the health status of patients utilizing the appropriate coding rules, guidelines and HIPPA requirements.
Duties include, but are not limited to:
- Identify, compile, abstract, and code patient medical data, using standard classification systems.
- Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team’s regular meetings.
- Ensure accurate assignment of all medical codes.
- Identify discrepancies in documentation.
- Audit appeals of denied claims.
- Consult classification manuals to locate information about disease processes.
- Maintain privacy of medical records.
- Classify information about illnesses, diagnoses, and treatment using standardized codes and guidelines.
- DRG and APC assignment analysis to accurately reflect the diagnosis and procedures documented in the medical record
- Documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements.
- Maintain HIPAA compliance at all times.