Lead Coder

• Review Medical Records to identify diagnoses/procedures.


• In concert with Coding Department management staff, organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.


• Demonstrates an in-depth knowledge of diagnosis and procedure coding, including sequencing of codes and present on admission assignment in conformance with ICDCM/PCS, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.


• Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated, involved encounters/cases.


• Assigns Codes


• Codes accurately and completely all diagnostic and operative information and professional hospital E/M services from the medical record using ICD-CM/PCS, CPT, and HCPCS coding classification systems.


• Accurately selects the DRG for each inpatient case and reviews DRG discrepancies to ensure the appropriate DRG assignment.


• Verifies and abstracts all required data elements from the record as required for billing and data reporting.


• Corrects data as appropriate.


• Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, and CMS, regional and local policy.


• Serves as an expert resource for the coders and others with coding questions and inquiries.


• Supports and mentors the coders and provides coder training as necessary.


• Medical Record Coding Review:  On a regular, scheduled basis, performs ongoing review of selected inpatient and outpatient cases to ensure correct assignment and sequencing of codes.


• Participates in quality improvement peer review for coding, abstracting, and DRG/APC assignments performed within the Coding Department.


• In concert with the Coding Department management staff, identifies departmental performance/quality improvement opportunities.


• Based on assessed and/or identified needs, conducts training and in-service education for assigned staff and serves as an experts on ICD/CPT/HCPCS and DRG/APC assignments, issues and projects.


• Completion of Medical Records: Interacts with physicns to clarify and accurately document patient diagnostic and procedural information.

• Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.


• Demonstrates knowledge of security of systems by not sharing computer logons.


• Other Duties: Acts as a resource person to other hospital departments regarding coding questions and issues.


• Other duties as assigned by supervisors.

Grade 715