Job Description
Description Summary of Performance Expectations: Responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. Communicates need for improved documentation to providers to assure appropriate reimbursement for services provided and assure evidence-based practice gu
8:00 AM
Coders start the day by pulling their assigned chart queue. In a hospital setting, an inpatient coder might work 15–25 charts per…
8:30 AM
Open the first chart. Read the operative report, discharge summary, and physician notes. Assign the principal diagnosis code (the…
10:30 AM
Encounter a complex chart — a patient with multiple comorbidities and a surgical complication. You spend extra time to capture eve…
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