Inpatient Coder provides inpatient coding utilizing ICD-10-CM and ICD-10 PCS Coding Classification systems. Utilizes an encoder and computer assisted coding software to achieve accuracy and thorough coding. Researches complex coding scenarios and queries physicians on documentation for clarification.

This is inpatient coding position for an experienced, trained inpatient coder. An Inpatient Coder analyzes clinical documentation; assign appropriate diagnosis, procedure, and, in some cases, abstract the codes and other clinical data. This information is then used to determine reimbursement levels, assess quality of care, study patterns of illness and injuries, compare healthcare data between facilities and between physicians, and meet regulatory and payer reporting requirements. Assist in the resolution of clinical documentation and provide feedback to providers on the quality of their documentation.

• Code and abstract clinical and demographic data for inpatient admissions using standardized coding regulations, abstracting rules, and Fairview guidelines.
• Utilizes technical coding principals and/or MS-DRG/APR-DRG reimbursement expertise to assign appropriate ICD-10 Diagnoses/Procedures
• Identify and resolve clinical documentation and charge capture data discrepancies to improve quality of the clinical documentation, severity and reimbursement levels assigned, integrity of data reported.
• Assigns present on admission (POA) value for inpatient diagnoses and identifies non-payment conditions (HAC) and ensures correct reporting.
• Query providers for additional documentation according to established procedures and guidelines.
• Assist in education of multidisciplinary team members, including physicians, as it pertains to frequently changing mandated rules, regulations and guidelines.
• Evaluate, problem-solve issues and/or discrepancies, and recognize when additional information or documentation is required to accurately code records
• Maintains knowledge of, and complies with, all relevant laws, regulations, policies, procedures and standards.
• Actively participates in creating and implementing improvements.
• Performs other responsibilities as needed/assigned.

Required

Education

• Certificate program in coding or Associate degree in HIM

Experience

• One year of inpatient coding experience

License/Certification/Registration

• One of the following: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA)

Preferred

Education

• Registered Health Information Administrator (RHIA 4 year degree) or Registered Health Information Technician
• (RHIT 2 year degree) plus additional coding credential

Experience

• Two or more years of inpatient coding experience

License/Certification/Registration

• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA)