The Senior Coder is responsible for providing coding and abstracting services for clients on inpatient, outpatient, physician or emergency room medical records using ICD-9-CM and CPT coding systems. The Senior Coder uses established coding principles, software and his/her knowledge and experience to assign diagnostic and procedural codes after a thorough review of the medical record. the Senior Coder also performs quality assessments on coding and participates in the training of staff and clients in coding systems and guidelines. Essential Functions: Reviews medical records to identify pertinent diagnoses and procedures relative to the patients health care encounter. Selects and assigns ICD-9-CM and CPT codes to cases based on the documentation in the medical record, using appropriate reference materials. Selects the principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition. Ensures appropriate DRG assignment. Abstracts appropriate information from the medical record based on the guidelines provided by the client and after a thorough review of the medical record. Solicits clarification from the physician regarding ambiguous or conflicting documentation in the medical record using guidelines provided by the client. Solicits clarification from the clients management staff regarding questions on internal coding guidelines, coding workflow or process. May be required to provide education and training to clients and staff regarding ICD-9-CM, CPT and/or E & M coding systems. Conducts coding quality assessments for clients that include the design of data collection form, informal exit interview, and preparation of written report. Participates in Coding Roundtables through presentation of materials, articles and current issues related to coding and Health Information Management. Maintains current knowledge of the information contained in the Coding Clinic, CPT Assistant, and the Official Guidelines for Coding and Reporting. Maintains effective and professional communication skills. Contributes to a positive company image by exhibiting professionalism, adaptability and mutual respect. Demonstrates and supports good internal and external customer service.
United States (Nationwide)