Provide coding and abstracting services on inpatient, outpatient, physician, or emergency room medical records using the latest appropriate International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding systems. Thoroughly review medical records including charts and procedures, and assign diagnostic and procedural codes based on review results.
Principal Responsibilities:
- Responsible for reviewing patient records and codifying results for reimbursement or payment purposes.
- Responsible for abstracting, coding, and sequencing the classification of medical and surgical procedures, diagnosis, and treatment modalities on Impatient and Day Surgeries.
- Review appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions, and surgical procedures.
- Select the latest, most accurate and descriptive codes from the listings of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM), American Medical Association Current Procedural Terminology (CPT-4) coding system, and Healthcare Common Procedure Coding System (HCPCS).
- Assign Present on Admission (POA) value for inpatient diagnoses as a supplement for ICD-9 CM coding.
- Assign correct diagnostic related grouping (DRG) and perform coding compliance reviews. Follow official coding guidelines to review and analyze health records.
- Enter codes into computer system, extract required information from source documentation, and enter data into encoder and abstracting system.
- Abide by the Standards of Ethical Coding, set forth by the American Health Information Management Association (AHIMA), adhere to official coding guidelines, and maintain current knowledge of the information contained in the Coding Clinic, CPT Assistant, and the Official Guidelines for Coding and Reporting.
- Maintain strict confidentiality of all data records.
- Knowledge, understanding, and compliance with all applicable Federal and Local laws and regulations relating to job duties.
- Knowledge, understanding, and compliance with NCO policies and procedures.
- Maintain knowledge of functional area and company policies and procedures.
- Provide feedback to management concerning possible problems or areas of improvement.
- Make recommendations to implement improved processes.
- Perform other duties as assigned by management.
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URGENT! Medical Coder (Licensed Nurse) - Expert Global Solutions - Quezon City (National Capital Reg)
