Medical Coder

2. MEDICAL CODER- JOB DESCREPTION

• Medical coding is the transformation of narrative descriptions of diseases, injuries, healthcare procedures and observations into numeric or alphanumeric designations (that is, code numbers), following Guidelines and Rules. 
• Medical coding is used for a variety of application in clinical care, research, education and billing medical insurance claims.
• Medical coding provides a key step in the process of preparing and sending electronic claims (e Claims). 
• The medical coder is primarily responsible for abstracting and assigning the appropriate coding on the claims. In order to accomplish this, the coder checks a variety of sources within the patient’s medical record, (i.e. the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources) to verify the work that was done. 
• Then the coder must assign CPT codes, ICD10-CM codes and HCPCS codes (for consumable and supplies only) to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim.
• Activities are expected in encounters (visits), reflected in e claims as one or many of the following codes: CPT, HCPCS, DDC, CDT or DSL code. 
• Dubai, UAE is following ICD 10 CMS  CPT 4 2012 version and HCPCS codes.  DRG coding and E&M coding is not following in Dubai.

Job Responsibility :

• Audit OP and IP claims on a daily basis based on DHA guidelines and ensure that it is delivered with appropriate CPT and Diagnosis codes.
• Confirmation of  procedure codes for insurance Pre-approvals. 
• Review the OT summary immediately after the surgery for any revision of the procedure codes (Eg:- Addition of Service, Alteration in the procedure code).
• Validation of Discharge Summary at the time of Discharge.
• Analyzing the IP claims before discharge if final bill is needed. 
• If some changes have to be done during claim submission and XML generation, the concerned department is informed through an email.

Abbreviations:

ICD 10 CM- International Classification of Disease 

CPT- Common Procedural Terminology

HCPCS - Healthcare Common Procedure Coding System

DDC – Dubai Drug Codes.

CDT – Current Dental Terminology

DSL – Dubai Service List