Coder, Certified Inpatient
About The Position
Position Summary The Certified Inpatient Coder is responsible for the accurate diagnostic and procedural coding of medical records. #The Coder is also responsible for the accurate abstracting of medical, financial and demographic information, in addition to performing other events. # Core Duties and Responsibilities # ###Per standard process reviews and evaluates designated medical records to identify diagnoses and procedures and accurately assigns and sequences ICD CM, ICD PCS and/or CPT codes # ###Reviews medical record for proper assignment of diagnosis and procedure codes according to AHA coding guidelines # ###Contacts Physicians and Other Healthcare Providers to clarify diagnoses and procedures # ###Sequence codes appropriately for accurate DRG # ###Abstracts required data from the medical record, including, but not limited to, Attending Physician, Discharge Disposition, ICD-9-CM , ICD-10-CM, CPT #diagnosis and/or procedure codes, and Physician Consultation # ###Completes medical record abstracts # ###Verifies patient demographic data for accuracy and completeness by comparing data in computer system with the medical record # ###Reviews the accuracy and consistency of medical record documentation and brings any inconsistencies to the attention of the appropriate individual # ###Keeps up to date on coding and regulatory changes. #Maintains individual abstracting and review manual # ###Achieves a #Meets Expectations# rating on coding /DRG audits # ###Meets productivity standards for coding #
Requirements
- Certified Coding Specialist or eligible
- RHIT or RHIA
- 3 years experience as a medical coder in an acute care hospital setting
- Knowledge and understanding of healthcare reimbursement methodologies and billing procedures
- Knowledge of health information management functions and computer operations
- Complete understanding of current coding system and guidelines (both ICD 10 CM and PCS)
Responsibilities
- Per standard process reviews and evaluates designated medical records to identify diagnoses and procedures and accurately assigns and sequences ICD CM, ICD PCS and/or CPT codes
- Reviews medical record for proper assignment of diagnosis and procedure codes according to AHA coding guidelines
- Contacts Physicians and Other Healthcare Providers to clarify diagnoses and procedures
- Sequence codes appropriately for accurate DRG
- Abstracts required data from the medical record, including, but not limited to, Attending Physician, Discharge Disposition, ICD-9-CM , ICD-10-CM, CPT diagnosis and/or procedure codes, and Physician Consultation
- Completes medical record abstracts
- Verifies patient demographic data for accuracy and completeness by comparing data in computer system with the medical record
- Reviews the accuracy and consistency of medical record documentation and brings any inconsistencies to the attention of the appropriate individual
- Keeps up to date on coding and regulatory changes. Maintains individual abstracting and review manual
- Achieves a #Meets Expectations# rating on coding /DRG audits
- Meets productivity standards for coding
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Ambulatory Health Care Services
Education Level
No Education Listed
Number of Employees
1,001-5,000 employees
