As an Inpatient or Outpatient Coder, you will work under general supervision to assign diagnostic and procedural codes to patient charts of moderate to high complexity levels using ICD-9 and CPT, HCPCS, and any other designated coding classification system in accordance with coding rules and regulations.
Essential functions include but are not limited to:
- Reviews medical records for the determination and accurate assignment of all documented diagnoses and procedures.
- Assigns and sequence codes based on medical record documentation.
- Assigns appropriate discharge disposition.
- Abstracts and enters coded data and designated quality management data for hospital statistical and reporting requirements.
- Communicates documentation improvement opportunities and coding issues (discrepancies, physician queries, etc.) to the appropriate personnel for follow up and resolution.
- Serves as a functional resource for entry-level coders and mentors/trains other coders as needed.
- Codes all types of patient records (i.e., inpatient, outpatient with the exception of specialty coding).
- Registered Health Information Technician (RHIT)
- Registered Health Information Administrator (RHIA)
- Certified Coding Specialist (CCS)
- Minimum of two years technical coding experience that includes inpatient and/or outpatient
- Additional credentials such as CGCS, CPC-H or CPC-C preferred
- Experience in computerized encoding and abstracting in a Windows-based environment preferred