Assistant Clinical Coder-Coding

Responsible for abstracting and analyzing clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.

Responsibilities

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for outpatient (OP), emergency department (ED), or observation short stay.
• Oversee and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions, and surgical procedures.
• Adhere to official coding guidelines to ensure accuracy and completeness as supported by documentation.
• Clarify diagnosis and procedural information through a query process to ensure accurate coding.
• Assign Present on Admission (POA) value for inpatient diagnoses.
• Ensure accurate physician name for each service and accurate time and da...