Clinical Coder II

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The Clinical Coder is responsible for reviewing patient medical records and accurately assigning standardized codes using ICD and CPT/HCPCS classification systems. The primary goal is to ensure timely and accurate coding for billing, reimbursement, research, and statistical reporting purposes, while maintaining compliance with established coding guidelines and regulations.

1. Review patient medical records (e.g., physician notes, lab results, radiology reports, operative reports) to identify diagnoses and procedures.

2. Assign accurate ICD (International Classification of Diseases), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System) codes.

3. Ensure coding accuracy and consistency across medical records.

4. Adhere to established coding guidelines, coding conventions, official coding rules, and regulatory requirements (e.g., CMS, HIPAA).

5. Maintain confidentiality of patient information in accordance with HIPAA regulations.

6. Stay current with coding updates, changes in regulations, and industry best practices.

7. Abstract data and information from medical records for various reporting requirements.

8. Communicate effectively with physicians, nurses, and other healthcare professionals to clarify documentation and resolve coding discrepancies.

9. Research and resolve accounts that have failed in the billing/collection process due to issues surrounding diagnostic and procedure coding.

10. Codes a wider range of patient encounters, including more complex cases.

11. Demonstrates a solid understanding of coding guidelines and conventions.

12. Requires moderate supervision and can independently resolve many coding issues.

13. May assist with training new coders or providing guidance to Level I coders.

14. Identifies and reports potential coding errors or inconsistencies.