- Review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.
- Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes.
- Identify cases with clinical indicators that may require provider documentation clarification and/or specificity in order to accurately assign codes; collaborate with CDIS team as part of the clinical documentation validation and physician query workflows.
- Analyze code assignment and sequence to assure proper DRG assignments; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign the DRG.
- Analyze the medical record documentation for complications and comorbidities
- Analyze medical record documentation for optimum severity of illness and risk of mortality scores
- Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary
- Suggest and assist with workflow process improvements as appropriate. Participate in coding quality and productivity processes.
- Strictly follow HIPPA regulations to maintain patient data confidential.