OP Medical Coder

1.1 The incumbent checks and sequences the most accurate ICD-9/ ICD10- CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.

1.2 Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.

1.3 Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Computes and gives the correct DRG coding all inpatients cases.

1.4 Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

1.5 Analyzes doctors’ documentation to assure the appropriate Evaluation &
Management (E & M) levels are assigned using the correct CPT code.

1.6 Ensures coding is as per DOH guidelines and regulations.

1.7 Provides feedback to Doctors regarding coding errors or oversights.

1.8 Constantly updates to the latest coding versions and DOH coding directives.

• Check and assign accurate ICD-9/ICD-10-CM, CPT, HCPCS, DRG, and other relevant codes for diagnoses and procedures based on documented information, ensuring final diagnoses and operative procedures are valid and complete.

• Abstract essential information from health records to identify secondary complications and co-morbid conditions.

• Evaluate medical records for documentation accuracy, consistency, and adequacy, ensuring the final diagnosis reflects the treatment provided; compute and assign correct DRG codes for all inpatient cases.

• Provide training, guidance, and support to coders and Medical Records Technicians, including updates on new coding rules and regulations.

• Analyze physicians’ documentation to ensure appropriate Evaluation & Management (E&M) levels are assigned using the correct CPT codes.

• Ensure all coding practices adhere to DOH guidelines and regulatory standards.

• Provide feedback to physicians regarding coding errors, discrepancies, or areas for improvement.

• Stay updated on the latest coding versions, DOH directives, and industry coding updates.

A graduate of Bachelor’s Degree in Allied Health Sciences or related areas with at least two (2) years of coding experience with valid Certified Coding Associate (CCA) certification from American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification from American Academy of Professional Coders (AAPC).

Preferably one year experience of coding medical claims.