Medical Coder

Position Description:

Specializing in in CPTs, HCPCS and ICD 10 CM , the coder will play a crucial role in the healthcare revenue cycle by assigning accurate codes to inpatient hospital stays. The professional will ensure that medical records are coded in compliance with established coding guidelines, regulations, and industry standards. The primary focus is on capturing the severity and complexity of the patient's condition during their hospitalization.

Primary Responsibilities:

1. ICD, CPTs & HCPCS : Assign appropriate codes to reflect the patient's Diagnosis, procedures, and complications accurately for the Hospital Coding (ED pro fee and E/M)
2. Review Medical Records: Analyze inpatient medical records to extract relevant information for coding purposes.
3. Coding Guidelines Compliance: Adhere to official coding guidelines, including those set by the American Hospital Association (AHA) and CMS.
4. Collaboration: Work closely with healthcare providers, clinical documentation specialists, and other stakeholders to clarify documentation and ensure accurate coding.
5. Quality Assurance: Participate in regular quality assurance audits to maintain accuracy and consistency in coding practices.
6. Education and Training: Stay informed about updates in coding guidelines, regulations, and healthcare industry changes. Provide training to other staff members as needed.
7. HIPAA Compliance: Ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations regarding patient information confidentiality.