Medical Coder
Job Description
The primary focus of the role is the coding of commercial payor accounts for primarily outpatient surgery cases and secondarily inpatient hospital discharges.
The Coding Specialist will use appropriate and industry standard methodologies. The Coding Specialists will perform physician queries, will clarify documentation, and will participate in coding reconciliation processes in collaboration with the relevant Omega team members.
Major Responsibilities
Review, analyze and interpret the entire electronic medical record for the current admission or outpatient case to identify all diagnoses and procedures documented during the admission.
- Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology / disease processes.
- Identify cases with clinical indicators that may require provider documentation clarification and / or specificity in order to accurately assign codes;
collaborate with relevant team members as part of the clinical documentation validation and physician query workflows.
- Analyze code assignment and sequence to assure proper CPT or DRG assignments; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign the CPT or DRG.
- Analyze the medical record documentation for complications and comorbidities
- Analyze medical record documentation for optimum severity of illness and risk of mortality scores
- Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary
- Suggest and assist with workflow process improvements as appropriate. Participate in coding quality and productivity processes.
- Work with existing medical staff and team members to continuously improve the coding process.
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