Inpatient Coder Job Description
Inpatient coder
provides direction for recoding and denial resolution based on medical record documentation, correct coding guidelines and payer coverage policy guidance.
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:
Identifies and codes Inpatient records for the purpose of reimbursement, research, and compliance with federal regulations according to diagnosis and procedure using 1CD-9-CM and CPT-4 coding systems
Assigns the correct principal diagnosis, comorbidities and complications (CCs), secondary diagnoses, POA (Present on Admission) indicators, HAC (Hospital-Acquired Conditions), principal procedure codes, and secondary procedure codes according to official coding guidelines, the Coding Clinic, and in accordance with all official Uniform Hospital Discharge Data Set (UHDDS) definitions
Perform coding (applying the correct ICD-9-CM and CPT codes) of patient accounts
Collect and abstract all clinical and statistical information as required
Reviewing all patient files for accuracy
Codes and abstracts all necessary information, describes each documented diagnoses and procedures according to established HIM guidelines and AHIMA code of Ethics
Assists in implementing solutions to reduce back-end billing errors
Abstracts data elements to satisfy statistical requests by the hospital, health system, medical staff, and enters all coded/abstracted information into the hospital information system
Acts as a mentor for others
Registered Health Information Technician (RHIT) with associate's degree in health information technology from accredited program or Registered Health Information Administrator (RHIA) with bachelor's degree in health information administration from accredited program
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:
Medical terminology
Anatomy and physiology
Federal
Pharmacology
State and payer regulations
Accepted medical abbreviations and their meanings
Coding Clinic
Hospital information systems
Disease process
HCPCS and denial handling
Desired experience for inpatient coder includes:
Encoder experience (a plus)
2 to 5 years experience in medical records, including at least 2-5 years in a coder
3+ years of Inpatient medical coding experience (hospital, facility)
CCS, RHIA or RHIT preferred
High school or general education degree (GED) or equivalent technical training
Certified Coding Specialist (CCS) mandatory
Inpatient Coder Examples
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Inpatient Coder Job Description
Job Description Example
Our growing company is looking for an inpatient coder. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for inpatient coder
- 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
Qualifications for inpatient coder
- 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
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Inpatient Coder Job Description
Job Description Example
Our growing company is hiring for an inpatient coder. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for inpatient coder
- 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
Qualifications for inpatient coder
- 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
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Inpatient Coder Job Description
Job Description Example
Our innovative and growing company is looking for an inpatient coder. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for inpatient coder
- 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
Qualifications for inpatient coder
- 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
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Inpatient Coder Job Description
Job Description Example
Our company is hiring for an inpatient coder. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for inpatient coder
- 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
Qualifications for inpatient coder
- 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
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Inpatient Coder Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of inpatient coder. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for inpatient coder
- 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
Qualifications for inpatient coder
- 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