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Job Description
Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations
- Check and assign the most accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for documented diagnoses and procedures.
- Ensure that the final diagnoses and operative procedures documented by the physician are valid and complete.
- Abstract all necessary information from health records to identify secondary complications and co-morbid conditions.
- Evaluate medical records for documentation consistency and adequacy, ensuring the final diagnosis accurately reflects the care and treatment provided.
- Compute and assign the correct DRG coding for all inpatient cases.
- Provide training and guidance to coders and Medical Records Technicians, updating them on new coding rules and regulations as required.
- Analyze physicians' documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.
- Ensure coding complies with HAAD guidelines and regulations.
- Provide feedback to physicians regarding coding errors, discrepancies, or documentation oversights.
- Stay up to date with the latest coding versions and HAAD coding directives.
- Perform miscellaneous job-related duties as assigned.
- Perform any other duties assigned by the HOD from time to time within the scope of the job title.
- Comply with all OSH and infection control policies, standards, and procedures, and cooperate with hospital management to meet these requirements.
- Work in accordance with documented OSH procedures, instructions, and assigned responsibilities.
- Be familiar with emergency and evacuation procedures.
- Notify OSH hazards, incidents, near misses, and issues, and assist in the preparation of risk assessments and incident reports.
- Comply with waste management procedures and policies.
- Attend applicable OSH and infection control training programs, mock drills, and awareness sessions.
- Use appropriate personal protective equipment (PPE) and safety systems.
- Bachelor's degree in Allied Health Sciences or a related field.
- Minimum of two (2) years of medical coding experience.
- Valid Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification from the American Academy of Professional Coders (AAPC).
- Computer literacy with proficiency in Microsoft Office applications.
- Excellent command of spoken and written English.
Performance Criteria:
- Achieve core objectives in line with the expectations of management and stakeholders.
- Demonstrate the ability to work constructively and interact professionally with colleagues and stakeholders.
- Effectively coordinate multiple tasks, adapt to changing priorities, and meet established deadlines.