Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, and complications. Accurately sequences diagnoses & procedures and maintains 95% accuracy. Assigns ICD-10 and CPT Codes. Performs charge reconciliation to ensure all submitted charges are posted accurately to ensure proper compliance and proper reimbursement.
The Vascular Surgery Coder must be proficient in surgical coding for all Trauma Surgery type cases. E/M experience is also required for associated providers. The coder will review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10 Diagnosis codes, along with CPT/HCPCS codes as defined for the service type, for coding, billing, internal and external reporting, research as required, and regulatory compliance.
Seeking a detail-oriented Clinical Documentation Specialist to assist medical staff providers with accurate documentation in the medical record, involving daily review of physician documentation, tracking patient diagnoses and procedures, and ensuring accurate reflection of service levels.