Assign specific codes to medical records, sequencing and determining codes to accurately reflect the resources and procedures used in the care of the patients.
Ensure compliance with regulatory and third-party insurance requirements in utilizing the ICD-10-CM, PCS, CPT, and HCPCS LEVEL II coding books.
Correlate operation codes with diagnosis codes to ensure the most descriptive code is selected when more than one anatomical location is involved.
Perform quantitative analysis and checks medical record for completeness, accuracy, and compliance with regulatory requirements.
Analyze and interprets documentation in record, ensuring accuracy, internal consistency and correlation of recorded data and returns record to provider/area for correction/completion.
Identify and documents any incident which may denote a potential compensatory event or questionable breach of quality of care delivered.