The   incumbent   checks   and   sequences   the   most   accurate   ICD-9/ ICD10- CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information.  Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.

3.2 Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.

3.3   Evaluates the record for documentation consistency and adequacy.  Ensures that the final diagnosis accurately reflects the care and treatment rendered. Computes and gives the correct DRG coding all inpatients cases.

3.4    Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

3.5  Analyzes   doctors’  documentation   to   assure   the  appropriate   Evaluation   &

Management (E & M) levels are assigned using the correct CPT code.

3.6  Ensures coding is as per HAAD guidelines and regulations.

3.7   Provides feedback to Doctors regarding coding errors or oversights.

Responsibilities

• Assign accurate ICD-9-CM, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
• Validate that final diagnoses and operative procedures documented by physicians are complete and accurately coded.
• Abstract relevant information from health records to identify secondary diagnoses, complications, and co-morbidities.
• Review medical records for documentation consistency, completeness, and adequacy.
• Ensure the final diagnosis reflects the care and treatment provided and assign the correct DRG for all inpatient cases.
• Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians on coding practices and regulatory updates.
• Analyze physicians' documentation to ensure accurate assignment of Evaluation & Management (E&M) levels using the appropriate CPT codes.
• Ensure compliance with DOH (formerly HAAD) coding guidelines, regulations, and coding standards.
• Provide constructive feedback to physicians regarding coding discrepancies, documentation gaps, and missed coding opportunities.