Responsibilities

Under general direction, the Certified Coder accurately codes all diagnoses and procedures in the medical record and abstracts relevant information from these medical records. The Certified Coder uses this information to form the basis of a patient information system relating to the clinical care of the patient.

Essential Functions:

• Assign codes to diagnoses and procedures using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes.
• Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations.
• Follow up with the provider on any documentation that is insufficient or unclear.
• Communicate with other clinical staff regarding documentation.
• Search for information in cases where the coding is complex or unusual.
• Receive and review patient charts and documents for accuracy.
• Review the previous day's batch of patient notes for evaluation and coding.
• Ensure that all codes are current and active.