Coder - Hospital

The Medical Coder 3 (inpatient and ambulatory surgery) abstracts clinical information from a variety of medical records, charts and documents and assigns appropriate ICD-10 - CM/PCS and CPT codes to patient records according to established procedures. Works with coding databases and confirms DRG assignments. Familiar with standard concepts, practices, and procedures within a particular field. Relies on instructions and pre-established guidelines to perform the functions of the job.

This position relies on guidelines and some experience and judgment to complete job and works under general supervision.

• Coding/Abstracting Assists the Business Office and external agencies in clarification of coding regarding reimbursement issues. Handles all requests in a timely fashion.
• Quality/Performance Corresponds with other areas of the HIM department to ensure the necessary components are available for accurate coding and the highest quality of the patient's medical record.
• Maintains an accuracy rate of not less than 93% based on internal and/or external review and a productivity standard per 8 hour day, engages in problem identification and solving, and assists in data gathering and chart auditing as necessary.
• Demonstrates competencies in the service to our patients/customers of all ages by obtaining information in terms of customer needs. Speaks in a positive, professional manner about co-workers, physicians, and the facility.
• Attends meetings as required and strives to improve the quality of meetings by taking an active role in meeting topics. Participates in educational programs, in-services, and training sessions in an effort to share his/her own expertise with others and further the quality of education and personal growth provided to new personnel, volunteers, and interning students.
• DRG Coding Confirm APC Assignment Determines the appropriate sequencing of diseases, diagnoses, and surgeries. The Coder accurately assigns appropriate codes to patient records using ICD-9-CM system and CPT-4 guidelines.
• Other Duties as Assigned Performs other duties as assigned or requested.

Experience - RHIT/RHIA plus 5 years of acute care coding experience, or RHIT/RHIA with ICD-10 curriculum plus 3 years of acute care coding experience, or 7 years acute care coding experience; CCS substitutes for 1 year of acute care coding experience

Education - High School or equivalent