Inpatient Coder II

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POSITION SUMMARY : The Inpatient Coder II is the second level coding position in a 3-tier career ladder. Inpatient Coder IIs will evaluate inpatient medical records and accurately assign the appropriate ICD-10 CM / PCS codes, Present on Admission (POA) indicators, and relevant DRGs. The Coder II must be skillful in the identification and assignment of all diagnoses and procedures in accordance with nationally recognized coding guidelines, as well as researching opportunities to improve documentation.

Responsibilities

• Assigns appropriately sequenced and compliant ICD-10 CM / PCS codes as documented in the electronic medical record (EMR).
• Applies definition of principal diagnosis for proper assignment of MS-DRGs, APR-DRGs, and POA indicators using a designated encoder / grouper, while ensuring compliance with nationally established coding guidelines.
• Utilizes selected encoder and / or computer-assisted coding software (CAC) set forth by client and Accuity.
• Abstracts pertinent data from documentation in accordance with client, state, and federal reporting requirements.
• Identifies instances in which provider clarification is necessary to ensure quality, completeness of documentation, and optimal, compliant reimbursement and communicates to appropriate channels.
• Updates and / or recommends coding changes as necessary due to additions or revisions in physician documentation and Internal Controls and Quality.
• Maintains required standards of performance in both coding accuracy and productivity to meet client turnaround and satisfaction.
• Records accurate production logs, time keeping, and other relevant tracking information daily.
• Performs additional job-related duties as assigned from coding management within pre-determined schedule.
• Stays current with most recent coding changes and guidance from CMS, AHA Coding Clinics, AHIMA, Official Inpatient Coding Guidelines, as well as internal education from Physicians, CDI and Coding leadership.
• Completes required Continuing Education hours to maintain credential requirements.
• Participate in Coding department meetings and other events as assigned.
• Maintains a collegial working relationship with other departments.
• Accepts coaching, training, and education on a routine basis as needed.

Qualifications

POSITION QUALIFICATIONS :

Education :

Experience :

Knowledge, Skills, and Abilities :

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