Key Responsibilities
Review inpatient medical records and assign accurate ICD-10-CM and ICD-10-PCS codes.
Analyze clinical documentation to ensure appropriate DRG assignment and reimbursement.
Abstract and code diagnoses, procedures, complications, comorbidities, and discharge dispositions.
Ensure coding accuracy in accordance with official coding guidelines, payer regulations, and client requirements.
Perform coding quality reviews and maintain productivity and accuracy standards.
Query physicians when documentation is incomplete, inconsistent, or unclear.
Identify prospects for documentation improvement and collaborate with Clinical Documentation Improvement (CDI) teams.
Maintain compliance with HIPAA, patient confidentiality, and healthcare regulations.
Stay updated with coding guideline changes, DRG updates, and regulatory requirements.
Participate in internal audits, training programs, and quality initiatives.