Medical Coder

Roles and responsibilities

Codes patient medical records using the ICD-10-AM classification system.
Consults with physician through the Head of HIM when documentation of diagnosis and procedures is illegible, not clinically state or omitted in order to properly assign codes or when proper sequencing of diagnoses and/or procedures is unclear.
Filing of the coded records and maintains accurate, neat files in a timely manner.
Merging the double numbered records on the basis of proper and authorized request with coordination of MSD.
Maintains confidentiality, security and personal privacy of all patient information and files.
Codes diagnosis/procedure data for both inpatient and out-patient records, company reporting and generates daily reports.
Verifies the inpatient census report and adjusts accordingly on a daily basis and compiles a daily and monthly report.
Collection of statistical data from all the clinical departments to compute the statistics
Data entry in the HIS program for Ministry of Health and save in the disk to present to Ministry of Health through Head of the Department.
Utilizes the PC for maintaining and compiling of regular statistical reports and graphic presentation, enters the appropriate abstracting data.
Participates in on-going education program developed by the department, e.g. department policies and procedures, Fire and Safety, Risk Management, Environmental Control.
Participates in Monthly meeting to ensure that all the staff completing their job description according to the policy and procedure of the department and discussing current issues to keep the quality to the patient care services.
Performs other applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and abilities.
Reviewing Patient Records
Examining Medical Records: Reviewing patient medical charts, diagnostic reports, and physician notes to extract the relevant data for coding.
Understanding Medical Terminology: Applying knowledge of medical terminology, anatomy, and procedures to accurately translate complex healthcare services into standardized codes.
Ensuring Accuracy: Ensuring the correct codes are assigned to diagnoses, procedures, and treatments based on the medical documentation, while maintaining accuracy and attention to detail.
Assigning Medical Codes
Using Standard Coding Systems: Applying appropriate coding systems like the International Classification of Diseases (ICD) for diagnoses, Current Procedural Terminology (CPT) for procedures, and Healthcare Common Procedure Coding System (HCPCS) for services and equipment.
Choosing Correct Codes: Selecting the correct codes for diagnoses, procedures, treatments, and tests based on the patient’s medical condition, treatments, and services rendered.

Desired candidate profile

Certified coder
Minimum educational level of an associate degree
Experience:

Required
At least (2) years coding experience in an acute care hospital setting.

Competencies:

Fluency in verbal and written English.
Competent knowledge and understanding of current coding guidelines and principles.
Ability to understand diverse documentation style and read various diagnostic reports contained in the Medical Record.
Ability to operate computerized patient information system and the personal computer.
Exhibits professionalism and excellent interpersonal communication skills.
Insurance and Billing Support
Preparing Claims for Insurance: Preparing and submitting insurance claims with correct codes to ensure proper reimbursement for healthcare providers.
Insurance Verification: Verifying insurance information and understanding the requirements of different insurance companies to ensure claim accuracy and avoid denials.
Code Modifiers: Applying modifiers to codes when necessary to provide more specific information about the procedure performed (e.g., if it was a bilateral procedure or required a longer time).
Ensuring Compliance with Regulations: Ensuring that medical coding practices comply with government regulations, such as HIPAA (Health Insurance Portability and Accountability Act), and healthcare billing standards.
. Documentation and Record Keeping
Maintaining Accurate Records: Documenting all codes assigned to patient charts and ensuring these are maintained properly for future reference or audits.
Correcting Errors: Reviewing codes and correcting any errors or discrepancies in coding as they are identified through audits or claim rejections.
Tracking Services and Reimbursements: Monitoring the coding and billing process to track claims, payments, and any discrepancies that arise during billing or reimbursement.
. Collaboration with Healthcare Providers
Working with Physicians and Other Healthcare Professionals: Communicating with doctors, nurses, and other healthcare providers to clarify diagnoses, treatments, and procedures when necessary for accurate coding.
Requesting Additional Information: If a medical record is incomplete or unclear, contacting the relevant healthcare provider for additional details or clarification.
Educating Staff: Occasionally educating healthcare providers or administrative staff on proper documentation techniques to improve the coding process.