OP Medical Coder

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

• Reviews and sequences accurate ICD-9-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information.
• Ensures that final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
• Prepares daily and monthly coding audit reports.
• Abstracts all required information from medical records to identify secondary complications and co-morbid conditions.
• Evaluates medical records for documentation consistency, completeness, and adequacy, ensuring diagnoses accurately reflect the care and treatment provided.
• Ensures coding compliance with DOH guidelines, standards, and regulatory requirements.
• Provides timely and constructive feedback to physicians regarding coding errors, omissions, or documentation gaps.
• Remains updated with current coding systems, revisions, and DOH coding directives.
• Maintains effective intra- and inter-departmental communication to ensure smooth departmental operations.
• Strictly adheres to organizational policies and procedures, particularly those related to infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.
• Supports Continuous Quality Improvement (CQI) initiatives and actively participates in all quality assurance activities.
• Participates in scheduled in-service training programs, in-house activities, conferences, and other assigned educational programs.
• Maintains confidentiality in accordance with signed agreements and organizational policies.
• Demonstrates effective listening and communication skills to promote collaboration and teamwork.
• Develops a thorough understanding of hospital policies and procedures and demonstrates compliance at all times.
• Performs additional duties as assigned by the Head of Department.

Qualifications

• Graduate in Allied Health Sciences or a related field
• Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA)

Experience

• Minimum of two (2) years of coding experience

Skills

• Strong computer literacy
• Excellent oral and written English communication skills