Medical Records Coder

Performs coding and abstracting duties to ensure accurate completion of coding for all assigned patient records.

Responsibilities include:

• Analyzing and interpreting the medical record in its entirety to ensure accurate, complete, and consistent selection of diagnoses and procedures.
• Applying understanding of anatomy and physiology to interpret clinical documentation and identify applicable codes.
• Using online resources, manuals, and reference materials to determine appropriate codes and coding rules.
• Applying UHDDS definitions and regulatory guidelines to select principal and secondary diagnoses and significant procedures.
• Coding diagnoses and procedures in accordance with ICD-10-PCS official guidelines and reporting POA indicators.
• Assigning discharge disposition in accordance with CMS rules and regulations.
• Making independent coding determinations to avoid workflow delays.
• Managing multiple work demands while maintaining efficiency and turnaround standards for coding and DRG assignment.
• Assigning and reporting required data elements for SPARCS data collection, congenital malformations, and expirations.
• Applying CPT coding conventions and official outpatient coding guidelines for outpatient encounters.
• Generating compliant physician queries to clarify incomplete, ambiguous, or conflicting documentation.
• Recognizing the impact of coding decisions on the revenue cycle.
• Assisting in educating physicians and clinicians on proper documentation practices.
• Participating in ongoing hospital education to maintain coding skills and stay current with coding changes and regulations.
• Maintaining minimum data standards for accuracy and efficiency.
• Maintaining certified coding credentials and annual compliance.