Inpatient Coder Job Description
Inpatient Coder Duties & Responsibilities
To write an effective inpatient coder job description, begin by listing detailed duties, responsibilities and expectations. We have included inpatient coder job description templates that you can modify and use.
Sample responsibilities for this position include:
Inpatient Coder Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Inpatient Coder
List any licenses or certifications required by the position: CCS, AHIMA, APPC, RHIT, RHIA, GOLD, CCP, AAPC, CIRCC, CPMA
Education for Inpatient Coder
Typically a job would require a certain level of education.
Employers hiring for the inpatient coder job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Health, Nursing, Health Information Management, Associates, Medical, Education, Medical Terminology, Graduate, Physiology, Anatomy
Skills for Inpatient Coder
Desired skills for inpatient coder include:
Desired experience for inpatient coder includes:
Inpatient Coder Examples
Inpatient Coder Job Description
- Must be flexible to work any day for a 7~day a week operation, including weekends, holidays, various shifts, and days in order to accommodate staffing needs
- Communication with department manager/supervisor on coding, compliance and documentation issues
- Seeks clarification from healthcare providers or other designated resources to ensure accurate and complete coding
- Serves as back up coder for outpatient surgery, observations and diagnostics, as necessary
- Applies ICD-9-CM and CPT 4 coding system guidelines
- Interprets clinical data and applies Uniform Hospital Discharge Data Set definitions to identify the diagnostic and procedure codes
- Abstracts pertinent information from clinical notes, operative records, radiology reports, pathology, specialty forms, Interprets diagnostic workups, surgical techniques, advanced technology and special services, identifies medical and surgical complications and untoward events and enters into the abstracting computer system
- Serves as back up to Coder 2 or Coder 1 by training in and the coding of outpatient surgeries, observations, ED or diagnostic cases as required
- Reports discrepancies to the HIM Supervisor or Director when final abstract is unable to be sent due to physician related issues or lack of proper documentation
- May contact physician and/or ancillary departments, clarifying information with DRG Assurance staff when additional information is needed to accurately code the record
- Experience in a major academic medical center and ICD-10-CM coding and DRG grouper assignments
- Ability to assign ICD-10-CM, ICD-10-PCS and CPT-4 codes to medical records
- Must be a resident or willing to relocate in the states of TX, LA, AR, NM, GA, OK or IA
- Required - 5 years coding experience or demonstrated success in coding the most complex medical services with consistent accuracy
- CCS, RHIT or RHIA certification strongly preferred
- Associate's Degree in Health Information Technology preferred
Inpatient Coder Job Description
- Assures accuracy and timeliness of code assignments required to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care
- Assists in and participates in quality improvements activities of the HIM Department as assigned
- Supports special studies in relation to coding and abstracting information, as assigned
- Performs follow up coding of medical records as a result of internal or external reviews which identify coding, DRG or APC discrepancies
- Conducts selection/sequencing of principal and secondary diagnosis/principal procedures and secondary procedures done correctly at least 95% of the time
- Abstracts correctly all appropriate data elements at minimum 95% of the time
- Maintains knowledge and skills through a variety of methods including reading current coding resources, clinical information, in-services
- Meets and exceeds minimum standard productivity requirements outlined in departmental coding benchmarks
- Maintains flexibility to meet organizational demands for new skills and knowledge
- Provide remote medical records coding and abstracting services to our clients nationwide
- An Associate's Degree in Health Information Technology and registration with the American Health Information Management Association as a RHIT or RHIA is necessary
- RHIA or RHIT or CCS preferred
- Graduate of accredited Health Information Technology or Administration Program or completion of AHIMA Independent Study Program or completion of advanced coding classes in ICD-10-CM and CPT4 at an accredited college or vocational school preferred
- Ability to lift, lower, push, pull and retrieve approximately 10 percent of the time
- Ability to sit 90 percent of the time
- Ability to demonstrate safe retrieval skills from above head to floor level with objects up to ten pounds
Inpatient Coder Job Description
- All other work duties as assigned by Manager
- Completes final review of medical record and selects appropriate ICD-10 and CPT codes within designated deadlines
- Reviews records upon admission and periodically through hospitalization to assign working diagnosis and DRG, expected length of stay and identification of Core Measures as assigned
- Works collaboratively with the Clinical Documentation Specialists II to identify and address documentation deficiencies
- Assigns diagnostic and procedural codes in accordance with coding principles and established guidelines utilizing encoder software
- Identifies appropriate principle diagnosis and sequences all secondary diagnoses and procedures according to guidelines of the MS-DRG reimbursement system (applicable to all patients)
- Completes the discharge abstract by gathering pertinent patient stay data from record in addition to coded diagnostic and procedural data
- Acts as the primary point of contact for Inpatient Coders requiring assistance and may review coded medical records for coding quality assurance
- Provides instruction and feedback to Inpatient Coders regarding proper coding / DRG assignment as necessary
- Assists with on-the-job coaching of Inpatient Coders and fosters process improvements
- Associate or Bachelor’s Degree in Health Information, Nursing, or other related field, or formal coding classes completed and passed preferred
- Associate’s (RHIT) or Bachelor’s (RHIA) degree in Health Information or formalized inpatient coding training
- Requires high school diploma, minimum 2 years coding experience in ICD-10-CM, ICD-10-PCS and CPT 4 or will consider new graduate coding students in lieu of 2 years coding experience based coding test results provided
- Requires CCS – must obtain within 12 months of employment
- Associates degree in Medical Record Sciences with certification as a Registered Health Information Technician (RHIT), Registered Health Administrator (RHIA) or RHIT, RHIA certification eligibility
- Minimum of five years inpatient coding experience and/or two years coding experience at a level one trauma hospital
Inpatient Coder Job Description
- Provides recommendations to the Supervisor of Inpatient Coding for the most efficient utilization of assigned personnel
- Relays work instruction from the Supervisor of Inpatient Coding
- Distributes and monitors the flow of work for assigned staff and / or outside vendors
- Provides training and technical assistance to employees within the assigned work area
- Communicates to the Supervisor of Inpatient Coding when backlog situations arise or necessary documents are either incorrect or not received in a timely manner
- Refers all unusual, questionable situations to the Supervisor of Inpatient Coding
- Alerts management to any coding irregularities, or trends contrary to policies / procedures, so corrective measures may be taken
- May be required to accurately assign and / or correct the discharge disposition status based on clinical documentation to ensure proper reimbursement
- Based upon the assigned codes, utilizes the computerized 3M Encoder software to assign the most accurate DRG
- Initiates the retrospective query process when documentation is inconsistent, incomplete, ambiguous, or non-specific
- Certification as a Registered Health Information Technician (RHIT), Registered Health Administrator (RHIA) or RHIT, RHIA certification eligibility
- Associates Degree or Coding Certificate required
- 4 or more years experience in the appropriate coding area for which the Coder will be working
- CCA (Certified Coding Assistant) or CCS (Certified Coding Specialist) certification required
- Analytical and interpretation skills when applying coding guidelines and principles for correct code assignment and proper sequencing of diagnoses and procedures
- Ability to apply definition of principal diagnosis for accurate coding, MS-DRG and POA assignment
Inpatient Coder Job Description
- Maintains DRG and coding accuracy rate of not less than 95% for optimal reimbursement department productivity standards as outlined in department policies
- Participates in improvement efforts and documentation training for medical and clinical staff as it relates to coding practices and guidelines
- Keeps current with all coding updates and information related to correct coding
- ICD-10-CM and/or PCS codes for all reportable diagnoses and procedures
- Acts as resource person to hospital staffing coding and may provide education regarding coding changes/issues
- Meets productivity standard of assigning codes to a minimum of 15 medical inpatient or 35 ambulatory surgery records/day or 40 oncology/day
- Review and analyze inpatient, outpatient, and facility medical documentation
- Identify and communicate errors and opportunities for documentation improvement
- Proactively educate physicians and residents on professional inpatient, outpatient and facility documentation requirements
- Evaluate and reconcile claim edits
- Knowledge of ICD9-CM diagnosis and procedure coding guidelines, DRG and POA assignment
- Trained in ICD-10-CM and PCS with demonstrated proficiency
- Moderate skills MS Office Suite
- Demonstrate appropriate utilization of coding software and coding reference material to facilitate achieving accurate coded data
- Minimum of 1 year inpatient coding experience
- Requires a good understanding of ICD-9 coding (diagnosis and procedure) and inpatient guidelines