What are the responsibilities and job description for the Medical Coder position at North Caddo Medical Center?
This specialist ensures accurate assignment of codes to all diagnoses and procedures documented in all patients’ health records (inpatient, outpatient, and emergency room). The coder assigns the codes using the proper classification system of ICD-10-CM and CPT to all inpatient, outpatient and emergency room records. The coder is also responsible for entering all professional fee and facility fee charges received by a patient into the computer system for billing purposes.
Essential Job Functions include the following, but are not limited to:
Listed below is an outline of the major duties and responsibilities that you will be required to perform. As the medical transcriptionist you are delegated the authority, responsibility and accountability to carry out your assigned duties.
Even though your job description is broad, every effort has been made to make this outline as complete as possible. However, we must emphasize that you may be required to perform other related duties and activities.
Always uses their skill and knowledge of current mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes.
Always assigns and reports codes that are clearly and consistently supported by physician documentation in the health record.
Always consults physicians for clarification and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.
Always assists and educates physicians and other clinicians by advocating proper documentation practices, further specificity, and resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity, and the occurrence of events.
Always stays abreast of changes in codes, coding guidelines and regulations.