Description

Description Responsible for coding and analysis of complex inpatient medical records, utilizing ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification)ICD-10-CM (International Classification of Diseases 10th revision) coding guidelines and conventions for establishment of diagnosis and procedures. The coded information is utilized for reimbursement purposes, data retrieval, education, to support medical research activity, assessment of clinical care, evaluation of medical services, case mix for the facility, and identification of health care concerns for public health. Responsibilities Medical Records – InPatient Coder - THIS IS AN ON-SITE POSITION Thoroughly review, analyze, and interpret the entire medical record (electronic and hardcopy), including progress notes, consultation reports, physician orders, nursing notes, operative reports, pathology reports, radiology reports, laboratory results, medication records, other ancillary service reports, and the discharge summary to identify all diagnoses and procedures occurring/affecting the current admission. Apply knowledge of anatomy and physiology, disease process, pharmacology, to identify diagnoses and procedures documented in the medical record. Apply knowledge of the ...