Description The Inpatient coder reviews and analyzes documentation in the medical record for inpatient visits to ensure accuracy of diagnosis and procedure codes. Coder finalizes the coding and abstracting of the medical record according to ICD-10-CM/PCS, CPT, and HCPCS coding conventions and guidelines supported by the clinical documentation in the medical record. Coder analyzes diagnosis and procedure codes concurrently assigned by Clinical Documentation Specialists. The Inpatient Coder assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Sequence the diagnoses and procedures using official coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges. Resolve Inpatient billing edits. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA). Requirements Position Education / Qualifications: RHIA, RHIT, CCS or CIC required. Three to five years hospital experience required. Job Knowledge / Experience: Experience and/or advanced training in medical coding (MS/APR DRG’s, ICD-10-CM, CPT, HCPCS, ect...). Must have extensive knowledge of medical terminology, anatomy and physiology, knowledge of pharmacology and all major diseases. Requires reasoning ability and good independent judgment. Critical thinking skills are a must. Must have strong interpersonal skills and the ability to multi-task. 3M CRS software experience preferred. Requires good communication and organizational skills. Must have an understanding of laws and ethics related to health insurance, medical billing and the health insurance Portability and Accountability Act (HIPAA). Requires working with minimal to moderate interruptions. Must complete CE hours annually, according to certification requirements. Professional coding and billing experience a plus. Responsibilities Promotes the facility mission, vision and values by effectively communicating them to others. Accurately codes all inpatient diagnoses and procedures according to ICD-10-CM/PCS, CPT and HCPCS coding conventions and guidelines. Follows the AHIMA Standards of Ethical Coding to adhere to Coding Compliance guidelines. References ICD-10-CM/PCS, CPT, and HCPCS Level II code books as needed. Accurately attaches HCPCS Level I and level II modifiers when appropriate. Utilizes 3M Coding references daily for final coding. Utilizes computerized 3M Coding software. Meets quality standards of having 95% of charts coded accurately. Maintains a good working relationship within the department, other departments and medical staff. Codes all available records in a timely manner. Queries physicians for clarification when ambiguous or incomplete information is present. Communicates with Coding Manager to solve problems and clarify coding issues. Attends workshops, seminars or conferences that pertain to the position and that fulfill CE hour requirements. Reviews Coding Clinic updates and continuing education periodicals in a timely manner. Maintains ongoing education to stay abreast of updates in coding conventions and practices. Assists the business office with clearing reimbursement and denial issues. Clears Aeos in a timely manner. Notifies HIM staff of incomplete or un-scanned records through the tickler system. Adheres to the Health Information Management Policies and Procedures for coding. Adheres to the Coding Compliance Plan. Reports any inaccuracies or discrepancies in the medical record to the appropriate department so that necessary corrections can be made. Maintains confidentiality and safeguards all patient related information. Has ability to train and mentor junior staff members. Performs peer review and internal audits. Performs other duties as assigned. Physical Demands and Working Conditions Light/moderate lifting up to 20 lbs from the floor to shoulder height; must be able to assist other employees with lifting more than 20 lbs. Light/moderate carrying up to 20 lbs. Pulling hand over hand, pushing, repeated bending, stooping/bending, reaching above shoulder, climbing stairs, climbing ladders. Dual simultaneous grasping, depth perception needed, ability to see, identify colors, operate office and mechanical equipment. Ability to read, write, count, hear verbal communication without aid, operate personal vehicle, comprehend written/verbal communication. Other: ability to deal with stress. Works over 95% of time in an air‑conditioned environment with varying exposure to noise; minimal exposure to malodorous, infectious body fluids; some minimal exposure to noxious smells from cleansing agents. Minimal to no exposure to blood, body fluids or tissues; OSHA Category III. EEO and Legal Statements I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform. If applicable ____________ certification will be completed within _________ time frame of hire/transfer date. Employee signature: ________________________________ Date: ____________________ #J-18808-Ljbffr