Medical Coder

Job Summary

Health information coding involves transforming verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric codes. The coder reviews and analyzes health records to identify relevant diagnoses and procedures for patient encounters, then translates provider documentation into coded form for claims submission, reimbursement, and reporting.

Job Duties

• Review medical records for inpatient and outpatient hospital and professional encounters to identify principal diagnosis, secondary diagnoses, and procedures.
• Examine supporting documentation such as laboratory findings, radiology reports, scans, discharge summaries, histories and physicals, consultations, orders, and progress notes.
• Translate diagnostic and procedural phrases into coded form using procedure codes as required.
• Use encoder software to determine codes for diagnoses and procedures.
• Sequence codes to help maximize reimbursement appropriately and legally.
• Assign the appropriate DRG.
• Apply hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI initiatives, CPT Assistant guidance, and other standard coding resources.
• Query physicians when needed to clarify documentation and support complete, accurate coding.
• Review coding guidelines annually and recommend changes to improve coding and data management.
• Communicate new diagnoses, procedures, and technologies to the Coding Quality and Professional Manager so coding guidelines can be updated.
• Update and correct historical file data by completing and submitting claim action reports for quarterly reporting.