The Certified Coder is responsible for converting diagnoses and treatment procedures into codes using ICD classification systems. This role requires accurate sequencing of diagnoses and procedures to support reimbursement and ensure coding is completed accurately and on time.

Duties and Responsibilities

Review charts thoroughly to identify all diagnoses and procedures.
Contact physicians professionally when diagnosis information is missing or clarification is needed.
Ensure diagnoses and procedures are supported by physician documentation.
Assign and sequence codes correctly according to coding guidelines and government regulations.
Refer questions regarding diagnoses or codes to the Director/Coding Supervisor.
Use computerized coding and abstracting equipment.
Code all diagnoses and procedures in accordance with ICD-10-CM/PCS principles, guidelines, and regulations.
Maintain 95% accuracy for principal diagnoses and procedures.
Ensure data quality and optimize reimbursement under federal and state payment systems.
Serve as a resource to hospital staff for coding and HIM issues.
Maintain familiarity with all charting and coding requirements.
Demonstrate knowledge of the computer system.
Accept additional assignments as needed.

Working Conditions

Work is performed in an office setting with extended periods of sitting or standing. The role may involve exposure to infectious diseases, hazardous cleaning agents, body fluids, waste, and other unpleasant patient or unit conditions. Physical requirements may include exerting up to 20 pounds of force occasionally and up to 10 pounds frequently.