Inpatient Coder – Main Campus

Job Category: HIM
Job Type: Part Time
Job Location: Main Campus


This position supports the Mission of the Hospital through the provision of distinctive and compassionate care to our patients. This position assigns ICD-10-CM , CPT, and HCPCS codes, creating an APC or DRG group assignments, of diagnoses, surgical and treatment procedures. Abstracts pertinent information from all patient types. Codes and Abstracts chart in a timely manner. Monitors billing status report. Queries physicians. Maintains current knowledge of coding guidelines and reimbursement reporting requirements. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines (CPT assistant and Coding Clinic).

• Coding certification preferred from the American Health Information Management Association or the American Academy of Professional Coders.
• RHIA, RHIT, CCS, CCS-P, CCA, COC certification is required within six months of hire date.
• Ability to pass HIM department coding examination.
• One to Two (1 – 2) years coding experience in an acute care setting.
• Prefer someone with work experience as a coder or strong training background in coding and reimbursement from an AHIMA approved college or university.
• Courses required in Anatomy and Physiology, Pathology and Medical Terminology is required. Working knowledge of hospital computer systems. Detailed oriented. 3M Encoder experience preferred. Completion of an AHIMA approved program for coding (with certificate) or health information technology or administration that is AHIMA approved.

Responsible for coding and/or DRG assignment and/or APC assignment
• Ensures that records are coded within 3 days of discharge, excluding weekends and holidays.
• Concurrently reviews inpatient records, using MS-DRG worksheets, looking for accurate and complete physician documentation to support the severity of the patient’s illness and risk of mortality.
• Participates in concurrent interactions with physicians, nursing, other caregivers and HIM staff to improve quality and completeness of clinical documentation.
• Queries physician when documentation in record is inadequate, ambiguous, or unclear for coding purposes. Notifies physicians of missing documentation needed to code any record using a professional, tactful manner or “Physician Query” form.
• Correctly assigns physician query or progress note in computer system.
• Thoroughly reviews chart to ascertain all diagnoses/procedures.
• Codes all diagnoses/procedures in accordance to ICD-10CM and PCS coding manuals.
• Codes procedures with CPT4/HCPCS codes following regulatory requirements.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to coding guidelines (CPT Assistant and Coding Clinic).
• Uses optimizing screens 3M Encoder to assign the correct DRG/ASC.
• Utilizes computerized coding and abstracting applications.
• Consistently demonstrates ability to prioritize workload in a timely manner.
• Codes and abstracts each chart before going onto the next chart leaving no unfinished charts unless approved by the Director.
• Actively participates in the Orientation and training and in-servicing of peers (coding staff).
• Actively participates in coding and documentation education for residents and physicians.
• Monitors and works on the DNFB billing status report on a daily basis.
• Notifies the Coding Coordinator whenever working more than 48 hours behind the work deadlines.
• Assists the Director with state requirements and reports.
• Assists the Director with quarterly and bi-annual submissions of OSHPD data reports.
• Applies proper selection and sequencing of secondary diagnosis.
• Research OP reports for coding of Same Day Surgery charts.
• Acts as a resource to hospital staff regarding coding questions, changes and issues.
• Performs all other duties and responsibilities as assigned.

Salary: $30.46 – $38.07 per hour

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