Medical Coder - Inpatient

This position is responsible for final coding of inpatient accounts including acute care, mother/baby, inpatient rehab and skilled nursing. Inpatient coders follow coding conventions and guidelines to abstract, analyze and accurately assign ICD-10-CM diagnosis codes and ICD-10-PCS procedure CPT and HCPCS codes. Inpatient coders are required to utilize the computer assisted coding features of the encoder to accurately group DRGs and to validate diagnoses that group to an APR-DRG.

Assigns present on admission indicator codes in compliance with national quality measures. Abstracts and validates other data elements as required.

• Associates of Health Information Administration
• Preferred

• 2-3 Years Medical coding
• Required
• 1-2 Years Inpatient coding
• Preferred

• National Certification
• Required
• American Health Information Management Association: RHIA, RHIT, CCS

• Accurately reviews medical records and assigns diagnosis and procedure codes utilizing the computerized encoding software system; sequences codes to group to the correct DRG; assigns an appropriate POA indicator to codes. Submits post discharge physician queries to clarify ambiguous or conflicting documentation. Validates admission and discharge data; abstracts other required data.
• Follows the standards of professionalism set forth by AHIMA and AAPC. Ethically and accurately assigns diagnosis and procedure codes in compliance with the ICD-10-CM/PCS Official Coding Guidelines, Coding Clinic, and CPT procedure codes in accordance with the CPT guidelines and CPT Assistant guidance.
• Exhibits strong teamwork skills to identify and clarify clinical and coding issues. Collaborates with CDI team to ensure all relevant diagnoses are captured for quality measures. Offers coding education as needed and requests clinical education.
• Maintains certification and engages in continuing education activities. Stays up-to-date on coding changes, Coding Clinic advice, and payor regulations including national and local policies. Shares knowledge with the rest of the team.
• Able to work independently and maintain quality and productivity standards in a remote, HIPAA compliant home environment to ensure goals are met. Identifies and escalates any obstacles to fulfilling job responsibilities. Takes initiative to resolve technical issues and maintains strong communication with coding management.