The Coder reviews and analyzes medical record documentation to determine diagnoses and procedures that account and support the treatment and services performed. Utilizing the International Classifications of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT). The Coder translates the documented diagnostic and procedural information into coded data in accordance with regulatory agencies and hospital specific guidelines. The Coder enters the coded data and other abstracted data from the medical record into the electronic information system. Participates in chart review projects as assigned.
- Maintain confidentially, protecting patient information at all times: minimum information necessary to those with right and need to know
- Conduct a thorough review of the documentation available in the record, and accurately assign the appropriate principle and secondary, diagnosis and procedures
- Applies Current Procedural Terminology (CPT) coding convention and general guidelines published by the American Medical Association (AMA) for surgical and diagnostic procedure coding.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Association (AHIMA) and adheres to official coding guidelines.
- Abstract patient data correctly and accurately complete all required elements in the electronic information system. Follow department policy and UHDDS abstracting guidelines.
- Ensure all pertinent documentation is available in the record for final coding and abstracting.
- Discrepancies identified upon review of the medical record, for example in the content and quality of the transcribed report, are addressed appropriately.
- Consult with medical staff members when necessary, for purposes of clarification of diagnoses and/or procedures
- Queries are formulated well; are clear, concise, and affect efficient assistance to the medical staff member for timely and accurate query response, complete documentation, and final coding.
- Consistently update coding status in the abstract module. Monitor un-coded records, taking initiative to resolve any issues and ensure timely abstracting and coding of data