Description

Job Description

Job Description

1. The incumbent checks and sequences the most accurate ICD-9-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.
   1. Prepare daily& monthly coding audit reports. 
   2. Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
   3. Evaluates the record for documentation consistency and adequacy.  Ensures that the final diagnosis accurately reflects the care and treatment rendered. 
   4. Ensures coding is as per DOH guidelines and regulations.
   5. Provides feedback to Doctors regarding coding errors or oversights.
   6. Constantly updates to the latest coding versions and DOH coding directives.
   7. Maintain inter and interdepartmental communication for the smooth functioning of the department.
   8. Strictly adheres to organization’s regulations and policies especially those related to infection control, patient safety, ADOSH, DOH, JCI and ISO.
   9. Supports Continuous Quality Improvement and participates and contributes to all the quality assurance activities of the service. 
   10. Participates and contributes in scheduled in-service training programs, In house activities, conferences or other programs as requested.
   11. Maintains confidentiality as per the agreement signed.
   12. Demonstrates the ability to listen to others in promoting effective communication.
   13. Develops thorough understanding of policies and procedures of the hospital and demonstrates respect for them.
   14. Carries out other duties when requested by the Head of department.

Responsibilities

• Check and sequence the most accurate ICD-9-CM, CPT, HCPCS, DRG, and other codes for diagnoses and procedures. Ensure final diagnoses and operative procedures as stated by the physician are valid and complete.
• Prepare daily and monthly coding audit reports.
• Abstract all necessary information from health records to identify secondary complications and co-morbid conditions.
• Evaluate records for documentation consistency and adequacy; ensure the final diagnosis accurately reflects the care and treatment rendered.
• Ensure coding complies with DOH guidelines and regulations.
• Provide feedback to doctors regarding coding errors or oversights.
• Stay updated with the latest coding versions and DOH coding directives.
• Maintain inter- and intra-departmental communication for smooth functioning of the department.
• Strictly adhere to the organization’s regulations and policies, especially those related to infection control, patient safety, ADOSH, DOH, JCI, and ISO.
• Support Continuous Quality Improvement (CQI) and actively participate in all quality assurance activities of the service.
• Participate in scheduled in-service training programs, in-house activities, conferences, or other programs as requested.
• Maintain confidentiality as per the signed agreement.
• Demonstrate active listening and promote effective communication within the team.
• Develop a thorough understanding of hospital policies and procedures and demonstrate respect for them.
• Carry out other duties as assigned by the Head of Department (HOD).

Qualifications

Language Skills: Excellent command of oral and written English.
 

Education: Graduate in Allied Health Sciences or related areas.

Certification: Certified Coding Associate (CCA) from the American Health Information Management Association (AHIMA).

Experience: Minimum 2 years of coding experience.

Technical Skills: Computer literacy.