Inpatient Coder

Job Responsibilities:

Assign ICD10CM and

ICD10PCS

codes to inpatient diagnoses and procedures, ensuring accurate MSDRG or APRDRG grouping in accordance with official guidelines and internal policies. Complete the appropriate number of coded records based on departmental productivity standards and accuracy requirements. Abstract key clinical and demographic information from patient records to support billing, quality reporting, and regulatory compliance. Utilize computerassisted coding (CAC) tools, encoders, and official coding references to support consistent and accurate code selection. Initiate physician queries when documentation is incomplete, ambiguous, or unclear to ensure accurate code assignment and clarify clinical intent. Collaborate with Clinical Documentation Improvement (CDI) professionals to enhance documentation quality and identify areas for physician education. Remain current with updates to coding guidelines, reimbursement requirements, and regulatory standards impacting inpatient coding. Maintain patient confidentiality and comply with medicolegal standards, including record amendment procedures and release of information policies.

Position Qualifications:

Minimum Required:

RHIA certification with a Bachelors Degree in HIM; OR RHIT certification with an Associates Degree in HIM; OR CCS certification. RHIT credentials must be received within 6 months of start date. CCS credentials must be received within one year of start date. Six months of coding experience.

Preferred:

Two years experience with inpatient coding. Experience with encoding systems. Work Environment All work is performed in an office where employees utilize their own workspace, however are in close quarters with other coworkers. Frequent interruptions often take place in responding to customer requests. The office is air conditioned as well as heated. Age of Patients Served Not Applicable HIPAA RolesBased Access to Patient Information All Access to patient information, including restricted information Level 4