Job Description:
PURPOSE OF JOB: Performs a detailed analysis of documentation in patient medical records, assigns the appropriate diagnostic and procedural codes for hospital reimbursement, data retrieval, and statistical analysis.

I. ESSENTIAL FUNCTIONS:

• Codes ICD-10 CM or CPT/HCPCS codes, creating MS-DRG, APR and APC group assignments.
• Communicates with the physician and/or hospital department(s) for clarification of registration and documentation issues.
• Keeps abreast of coding guidelines and reimbursement reporting requirements. Reports concerns to Coding Manager for resolution.
• Abides by the Standards of Ethical Coding as defined by the American Health Information Management Association and adheres to official coding guidelines and hospital and departmental policies and procedures.
• Performs other HIS-related duties as required.

Job Qualifications:
V. QUALIFICATIONS:

Certified INPATIENT Coder:

A. Education: High School diploma or equivalent

B. Experience:

1. Inpatient Coders - 2 years previous coding experience in a healthcare setting

C. Other Skills: Knowledge of anatomy, physiology, and medical terminology.

• Ability to demonstrate knowledge of coding guidelines and principles.
• Ability to abstract pertinent clinical information from the medical record into 3M coding products and Meditech.
• Ability to enter coding and physician information into a computer to ensure compliance with ethical coding guidelines and to ensure quality data abstraction.

D. License and Certification and Registration: Inpatient Coders- CCS required