The Certified Coder is responsible for converting diagnoses and treatment procedures into standardized codes using ICD-10-CM/PCS coding principles. The role requires accurate sequencing of diagnoses and procedures to support timely coding, data quality, and optimal reimbursement.

Key Responsibilities

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

Work Environment

Office-based position with extended periods of sitting or standing.
May involve exposure to infectious diseases, hazardous cleaning agents, body fluids, and waste.
May require lifting up to 20 pounds occasionally and up to 10 pounds frequently.