Inpatient Coder

The Medical Coder 3 (inpatient and ambulatory surgery) abstracts clinical information from a variety of medical records, charts and documents and assigns appropriate ICD-10 - CM/PCS and CPT codes to patient records according to established procedures. Works with coding databases and confirms DRG assignments. Familiar with standard concepts, practices, and procedures within a particular field. Relies on instructions and pre-established guidelines to perform the functions of the job. This position relies on guidelines and some experience and judgment to complete job and works under general supervision.

1. Coding/Abstracting
   1. Assists the Business Office and external agencies in clarification of coding regarding reimbursement issues. Handles all requests in a timely fashion.
2. Quality/Performance
   1. Corresponds with other areas of the HIM department to ensure the necessary components are available for accurate coding and the highest quality of the patient's medical record.
   2. Maintains an accuracy rate of not less than 95% based on internal and/or external review and a productivity standard per 8-hour day, engages in problem identification and solving, and assists in data gathering and chart auditing as necessary.
   3. Demonstrates competencies in the service to our patients/customers of all ages by obtaining information in terms of customer needs. Speaks in a positive, professional manner about co-workers, physicians, and the facility.
   4. Attends meetings as required and strives to improve the quality of meetings by taking an active role in meeting topics. Participates in educational programs, in-services, and training sessions in an effort to share his/her own expertise with others and further the quality of education and personal growth provided to new personnel, volunteers, and interning students.
3. DRG Coding Confirm APC Assignment
   1. Determines the appropriate sequencing of diseases, diagnoses, and surgeries. The Coder accurately assigns appropriate codes to patient records using ICD-9-CM system and CPT-4 guidelines.
4. Other Duties as Assigned
   1. Performs other duties as assigned or requested.

Experience - RHIT/RHIA plus 5 years of acute care coding experience, or RHIT/RHIA plus 3 years of acute care coding experience, or 7 years acute care coding experience; CCS substitutes for 1 year of acute care coding experience.

Education - High School or equivalent