Medical Coder

Role & responsibilities:

Review Profee medical records and assign accurate ICD 10-CM and CPT

codes of diagonis and procedures

Assign sequence codes accurately based on medical record
Thorough understanding and application of medical necessity, APC for processing charts.

Key Roles and Responsibilities

• Medical Record Review and Abstraction:

  The coder reviews extensive and often graphic medical documentation, including physician's notes, surgical reports, lab results, and radiology findings, to extract all relevant information.

• Code Assignment and Sequencing:

  They assign the correct codes from standardized systems such as:

• ICD-10-CM/PCS:

  Used for diagnoses and inpatient procedures. This can involve 25-30 diagnoses for a single critical patient.

• CPT:

  Used for surgical, diagnostic, and medical procedures and services, particularly in outpatient and professional fee settings.

• HCPCS Level II:

  Used for supplies, equipment, and services not covered by CPT.

• Ensuring Accuracy and Compliance:

  Coders must ensure that all assigned codes are accurate, complete, and sequenced correctly according to federal, state, and insurance company guidelines. This includes adhering to specific rules for trauma coding, where standard approaches may be altered by extreme circumstances.

• Physician Queries:

  When documentation is insufficient, vague, or conflicting, the coder must communicate effectively with physicians and other clinical staff to obtain clarification and ensure thorough documentation.

• Collaboration with Billing Department:

  The coder works closely with the billing department to ensure the codes are submitted correctly for timely reimbursement and to resolve any claim denials or errors.

• Data Management and Analysis Support:

  The accurate data provided by coders is used for quality assessment, research, tracking national health trends, and public health statistics.

• Auditing and Quality Improvement:

  They may conduct internal or external chart audits and participate in clinical documentation integrity (CDI) programs to improve overall documentati
• on practices and coding accuracy.

• Maintaining Expertise:

  Medical coders must engage in ongoing education to stay current with frequent changes and updates in coding guidelines, regulations, and medical technology.

In a trauma setting, the medical coder's specialized knowledge is crucial for capturing the complete severity of injury (acuity), complexity of care, and risk of mortality to ensure accurate data and appropriate reimbursement for the high level of care provided.