Medical Records Coder

Position Summary:

The Medical Coder is responsible for reviewing patient medical records and accurately assigning diagnosis and procedure codes using current ICD coding standards and applicable regulatory guidelines. This position ensures the integrity, accuracy, and completeness of coded data for billing, reporting, reimbursement, and quality improvement purposes. The Medical Coder also assists with medical record abstraction, reporting, and communication with providers regarding documentation requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Review patients' complete medical records and assign appropriate diagnosis codes using the International Classification of Diseases (ICD) system.
• Determine the correct sequencing of diagnoses in accordance with Uniform Hospital Discharge Data Set (UHDDS) guidelines and applicable coding standards.
• Assign appropriate procedure codes for surgical and designated diagnostic procedures.
• Record and maintain required data elements including attending physician, consultations, referral sources, and other applicable information.
• Query providers when documentation is incomplete, inconsistent, or unclear to ensure accurate code assignment.
• Maintain current knowledge of coding regulations, procedures, and industry guidelines.
• Monitor coding accuracy and quality through periodic reviews, audits, and analysis of coding corrections identified through computerized edits.
• Abstract clinical and administrative data within MIRA and other applicable systems for reporting to regulatory agencies, third-party payers, providers, and hospital administration.
• Serve as a liaison between hospital departments, medical staff, and external agencies regarding coding assignments and operational issues.
• Prepare periodic reports and other documentation as requested.
• Attend continuing education courses, seminars, and training programs to maintain coding proficiency and certification requirements.
• Provide assistance with departmental and office functions as assigned.
• HIM Clerk duties, like records request, recording QI and spreadsheets