Inpatient Coder/Abstractor (773) 

JOB SUMMARY:

Abstracts clinical information from medical records. Assigns appropriate ICD-10-CM and ICD-10-PCS codes and confirms appropriate DRG payment group assignment.

QUALIFICATIONS:

JOB SPECIFIC CORE COMPETENCIES

• Aptitude for detail and accuracy.
• Ability to analyze information and make independent judgments.
• Working knowledge of the ICD-10 coding systems, medical terminology, anatomy and physiology.
• Experience in computer operations.
• Types accurately at least 30 WPM.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Assigns ICD-10-CM diagnosis and ICD-10-PCS procedural codes in accordance with coding and reimbursement guidelines including, but not limited to, the following:
  • Identifies principal and secondary diagnoses and procedures based upon UHDDS standards.
  • Uses fifth digit and sequencing conventions.
  • Documentation is present to substantiate codes assigned, confirms all queries/clarifications have been completed before final coding the account.
• Abstracts relevant clinical and demographic information from the medical record for specificity of coding and reimbursement purposes.
• Maintains a control system to assure completeness of the indexing system; enters all corrections in response to system edits and internal controls.
• Serves as a coding resource for Patient Financial Services and Revenue Cycle.
• Refers coding and system questions to the supervisor/Director in a timely manner for determination and guideline development.
• Assists in abstracting and retrieval of data for selected studies requested by Quality.
• Keeps current on coding guidelines, rules and regulations, and new codes.
• Participates in coding reviews related to the denials and appeals processes.
• Other duties as assigned.

EXPECTED BEHAVIORS

• Accuracy: Accurately codes all diagnoses and procedures measured by Coding Quality Audits: 97 percent of all records for which the employee is responsible must be coded accurately to maximize DRG/APC weight.
• Productivity Level: Inpatient coding: 20 minutes/record.
• Productivity Calculation: Inpatient: 20 min/record x_________charts.
• Coded accounts are monitored to assure required fields for each patient type are consistent and complete.
• Corrects appropriate coding and abstracting discrepancies.
• Assists Patient Financial Services in clarification of coding vs. reimbursement issues.
• Seeks assistance only after referring to own resources.

MANDATORY LICENSE/REGISTRATION/CERTIFICATION:

CERTIFICATION/LICENSE:

• Certified Coding Specialist (CCS) required. If hired without CCS certification, must obtain within first 12 months of hire.
• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) accepted. If hired without CCS certification, must obtain within first 12 months of hire.

MANDATORY CONTINUING EDUCATION

• Yearly attends one or more seminars in ICD-10-CM and/or ICD-10-PCS coding.
• Mandatory Continuing Education: Customer Service, Fire and Safety, Corporate Compliance (including Confidentiality), Infection Control, and education required by regulatory, accreditation bodies, scope of practice, and/or Hancock Regional Hospital.