Job description
- Coding and Abstracting:
- Assign appropriate ICD-10-CM, CPT, and HCPCS codes to diagnoses, procedures, and services based on medical record documentation.
- Abstract relevant information from medical records and ensure completeness and accuracy in coding.
Quality Assurance:
- Conduct thorough reviews of coded medical records to ensure compliance with coding guidelines, regulations, and organizational policies.
- Provide feedback and education to junior coders to enhance coding accuracy.
Auditing and Compliance:
- Perform regular coding audits to identify potential compliance issues and coding discrepancies.
- Stay updated on changes in coding regulations and implement necessary changes in coding practices.
Clinical Documentation Improvement (CDI):
- Collaborate with healthcare providers and CDI teams to improve the quality of clinical documentation for accurate coding.
- Educate providers on coding and documentation best practices.
Reporting and Analysis:
- Generate reports on coding accuracy, productivity, and compliance for management review.
- Analyse coding data trends and provide insights for process improvement.
- Provide training and mentorship to junior coders and other healthcare staff on coding guidelines and updates.