Overview
The incumbent checks and sequences the most accurate ICD-9-CM, CPT, HCPCS, DRG, and 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.
Responsibilities
- Check and sequence the most accurate ICD-9-CM, CPT, HCPCS, DRG, and other codes for diagnoses and procedures. Ensure final diagnoses and operative procedures as stated by the physician are valid and complete.
- Prepare daily and monthly coding audit reports.
- Abstract all necessary information from health records to identify secondary complications and co-morbid conditions.
- Evaluate records for documentation consistency and adequacy; ensure the final diagnosis accurately reflects the care and treatment rendered.
- Ensure coding complies with DOH guidelines and regulations.
- Provide feedback to doctors regarding coding errors or oversights.
- Stay updated with the latest coding versions and DOH coding directives.
- Maintain inter- and intra-departmental communication for smooth functioning of the department.
- Strictly adhere to the organization’s regulations and policies, especially those related to infection control, patient safety, ADOSH, DOH, JCI, and ISO.
- Support Continuous Quality Improvement (CQI) and actively participate in all quality assurance activities of the service.
- Participate in scheduled in-service training programs, in-house activities, conferences, or other programs as requested.
- Maintain confidentiality as per the signed agreement.
- Demonstrate active listening and promote effective communication within the team.
- Develop a thorough understanding of hospital policies and procedures and demonstrate respect for them.
- Carry out other duties as assigned by the Head of Department (HOD).
Qualifications
- Education: Graduate in Allied Health Sciences or related areas.
- Certification: Certified Coding Associate (CCA) from the American Health Information Management Association (AHIMA).
- Experience: Minimum 2 years of coding experience.
- Technical Skills: Computer literacy.
- Language Skills: Excellent command of oral and written English.