ICD Coder

Role & responsibilities

Medical Coding of Diagnoses & Procedures

• Assign appropriate

  ICD-11 (International Classification of Diseases)

  codes for all diagnoses, diseases, and conditions mentioned in patient records.
• Apply

  CPT/HCPCS

  codes for medical procedures, surgeries, and treatments.
• Ensure accurate coding for

  inpatient, outpatient, emergency, and specialty departments

  .

Review of Clinical Documentation

• Examine patient files including discharge summaries, physician notes, lab reports, radiology, and operative notes to extract relevant clinical data.
  
• Identify missing or unclear documentation and

  query physicians or clinicians

  for clarification.
• Ensure that documentation supports the codes assigned and is

  complete and accurate

  .

Data Accuracy & Compliance

• Ensure all coding complies with

  national and international coding standards

  .
• Adhere to regulatory norms set by

  NABH, JCI, or ISO

  , and hospital-specific policies.
• Maintain updated knowledge of

  ICD revisions, coding guidelines, and payer-specific requirements

  .

Billing and Reimbursement Support

• Work with the billing department to ensure that coding supports appropriate claims processing and reimbursement.
  
• Help resolve claim denials or rejections related to coding errors or discrepancies.
  
• Participate in

  coding audits

  to verify billing integrity and reduce revenue loss.

Data Reporting & Analysis

• Contribute to generating

  morbidity, mortality, disease surveillance

  , and other epidemiological reports.
• Assist in

  data abstraction

  for medical research, performance indicators, and public health reporting.
• Provide coded data for medical audits, clinical research, and hospital statistics.
  

Coordination and Communication

• Coordinate with

  physicians, medical records officers, nurses, billing teams

  , and hospital IT.
• Escalate documentation issues and work collaboratively to improve data quality.
  
• Participate in meetings and training related to coding updates or compliance.
  

Confidentiality and Record Security

• Maintain

  strict confidentiality

  of patient health information (PHI).
• Adhere to

  data protection regulations

  and institutional privacy standards.
• Prevent unauthorized access or disclosure of medical records.