Certified Coder

The Certified Coder is responsible for converting diagnoses and treatment procedures into codes using an international classification of diseases. This role requires skill in sequencing diagnoses and procedures to optimize reimbursement and ensure records are coded accurately and in a timely manner.

Duties and Responsibilities

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

Working Conditions

• Office-based position requiring extended periods of sitting or standing.
• May be exposed to infectious and contagious diseases, hazardous cleaning agents, body fluids, and waste.
• May require lifting up to 20 pounds occasionally and up to 10 pounds frequently.
• Work is based on an average 8-hour shift and may vary depending on staffing volumes or departmental needs.