Inpatient Coder

JOB SUMMARY

The Inpatient Coder is responsible for accurately assigning diagnostic and procedural codes to patient health information for inpatient hospital services using ICD-10-CM/PCS coding systems. This position ensures compliance with official coding guidelines, payer requirements, and organizational policies. AAPC or AHIMA certification is required. The Inpatient Coder will report to the Assistant Director of Patient Financial Services.

JOB REQUIREMENTS

Minimum Education

§  College degree in Coding or Health Information Management

§  Certification through AAPC (e.g. CIC, CPC-H) or AHIMA (e.g. CCS, RHIT, RHIA)

Minimum Work Experience

§  Minimum of 2 years of inpatient coding experience in an acute care hospital or similar setting.

Required Skills

§  Proficient in ICD-10-CM/PCS, DRG assignment, and medical terminology

§  Strong knowledge of anatomy, physiology, and disease processes.

§  Excellent attention to detail and analytical skills.

§  Ability to work independently and meet deadlines.

§  Experience with 3M CRS, preferred

§  Prior participation in internal or external coding audits, preferred

§  Knowledge of risk adjustment and HCCs (if applicable).

FUNCTIONAL DEMANDS

Physical Requirements

Sitting - Greater than 32%

Walking - 1-15%

Standing - 1-15%

Bending/Squatting - 1-15%

Climbing/Kneeling - 1-15%

Twisting - 1-15%

OSHA Category

Minimal potential for direct body fluid exposure

Visual and Hearing Requirements

Must be able to hear clearly with assistance.

Must be able to see with corrective eyewear.

Other Physical/Environmental Demands

Lifting - 0-50lbs, 50lbs or more with assistance

Carrying - 0-50lbs, 50lbs or more with assistance

Pulling - up to 100lbs 

Pushing - up to 100lbs

LEADERSHIP CAPABILITIES

Supports the hospital Mission, Service and Values.

ESSENTIAL FUNCTIONS

§  Assign and sequence diagnosis and procedure codes for inpatient encounters in accordance with ICD-10-CM/PCS, MS-DRG, APR-DRG, and coding guidelines.

§  Review clinical documentation to ensure accuracy and completeness of codes used to reflect the patient’s condition and treatment.

§  Ensure coding compliance with federal regulations, third-party payers, and organizational policies.

§  Abstract required clinical information from the medical record.

§  Collaborate with physicians and clinical staff for clarification and additional documentation when needed (CDI queries).

§  Meet established productivity and accuracy standards.

§  Keep up-to-date with coding changes, payer regulations, and compliance guidelines.

§  Participate in coding audits and provide feedback to improve documentation and coding accuracy.

§  Maintain confidentiality of patient records in accordance with HIPAA regulations.

§  Other duties as assigned