IP surgery coder

Job Summary:

The Inpatient (IP) DRG Medical Coder is responsible for accurately assigning diagnostic and procedural codes to inpatient medical records based on the guidelines provided by the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Diagnosis-Related Group (DRG) coding systems. The coder ensures that the codes assigned are accurate, compliance with DOH regulations and insurance requirements.

Key Responsibilities:

• Review and analyze patient records: Examine doctors' notes, medical documents, diagnostic reports, drug administration charts and other records ensuring that all diagnoses and procedures are properly documented.
• Assign codes: Use ICD 10 CM (International Classification of Diseases - 2021 guidelines) and CPT (Current Procedural Terminology - 2021 guidelines) and E&M (Evaluation and Management - 2018 guidelines) systems to assign standardized codes.
• DRG Assignment: Determine the appropriate DRG for each inpatient case based on the primary and secondary diagnoses, procedures, and other clinical data in the medical record.
• Compliance: Ensure coding practices are in full compliance with DOH regulations and Daman, ADNIC and other payer-specific guidelines. Follow all coding conventions and guidelines outlined by ICD-10, CPT, and DRG protocols.
• Medical Record Review: Review physician and clinical documentation to ensure completeness, accuracy, and clarity, and query healthcare providers when necessary to clarify or complete documentation.
• Coding Audits: Perform coding audits and reviews to identify discrepancies, errors, or opportunities for improvement in coding accuracy.
• Billing and Reimbursement Support: Collaborate with the billing department to ensure correct coding for billing purposes and support accurate claims submissions for reimbursement.
• Ensure accuracy: Verify that all codes are accurate and compliant with regulations.