Inpatient Coder

Inpatient Coder

The Inpatient Coder will be responsible for accurately coding and abstracting diagnoses, procedures and clinical information from the medical record. The individual will adhere to established coding guidelines for data quality and integrity, as well as productivity. The Inpatient Coder plays an integral role in ensuring accurate and compliant coding of inpatient records. This position requires an individual with attention to detail, strong analytical skills, effective communication and collaboration skills. Duties and responsibilities include but are not limited to:

• Adherence to ICD-9, ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, CMS and other regulatory guidelines
• Applying the Uniform Hospital Discharge Data Set (UHDDS) definitions including regulatory guidelines to select the principal diagnosis, secondary diagnoses, & procedures utilizing MS-DRG, APR-DRG reimbursement expertise to assign appropriate ICD-10 CM and/or ICD-10-PCS diagnoses and procedures.
• Responsible for accurately assigning present on admission (POA) indicators for inpatient diagnoses.
• Accurately identifying hospital-acquired conditions (HACs) supported in physician documentation and reportable to corresponding quality committees.
• Verifying data and discharge disposition to assure coding compliance.
• Formulate appropriate queries in accordance with Guidelines for Achieving a Compliant Query Practice (2019 Update) for clarification of conflicting/ambiguous documentation, treatments or diagnostic tests given to patients for accurate code assignment and sequencing.
• Extracting required information from source documentation and enter into encoder and abstracting system.
• Reviewing daily pre-bill edits and coding errors to make corrections or complete missing data elements.
• Ability to collaborate with HIM Staff and Clinical Documentation Improvement Specialists (CDIS) to ensure the most accurate and complete documentation to support accurate coding/billing.
• Efficiently utilize Coding software and HIMS to abstract required data from patient visits in the appropriate coding assignments and timely billing in accordance with DNFB goals and established hospital policy and procedures.
• Attending continuing education workshops, webinars, etc., for coding compliance and maintenance of CEUs.