Job description
Inpatient Medical Coding
Inpatient Medical Coding job involves coding charts for patients whose treatment requires hospitalization for more than 24 hours. Inpatient Medical Coders use the coding systems ICD-9-CM, ICD-10 as well as DRG (Diagnoses Related Groups). Inpatient Medical Coding requires greater knowledge and experience because the groupings and sequencing of codes for specific diagnoses and procedures in a hospital are significantly greater.
Daily tasks usually include:
• Review patient histories, operations, chart reviews, consultation and discharge summaries to support codes selected for billing.
• Utilize ICD-9-CM and/or ICD-10 to select the diagnosis-related group (DRG) assignments for each case.
• Identify mistakes in reports.
• Enter coding information into electronic billing system.
Many Inpatient Medical Coders work for hospitals, although insurance companies and long-term health-care facilities may also employ inpatient coders. They typically must have at least 2 years of experience to be hired and may work at the facility or off-site in their homes. Hours vary based on the employer. Accuracy is critical in this position, as much of a hospital’s revenue depends on the correct coding of the diagnoses, procedures, and treatments administered. Coders often interact with physicians, nurses and other medical professionals in order to select the proper codes. Critical thinking and communication skills, great attention to detail and the ability to manage pressure without error are essential.
Training:
• High school diploma or certificate beyond high school and increasingly employers are specifying bachelor’s preferred. Inpatient Medical Coding programs can last from six months to two years.
• Familiarity with standard types of abstracting and encoder systems.
• AHIMA Certification: CCS (Certified Coding Specialist) or RHIT/RHIA (Registered Health Information Technician/Administrator).
• AAPC Certification: CPC-H (Certified Professional Coder – Hospital).

Job Recruitment Ad
Inpatient Coder Hospital Coding
Department: Coding
Shift: Day
Work Schedule: Day

POSITION SUMMARY

The Inpatient Coder is an advanced coding position that is responsible for accurately assigning codes to diagnoses and procedures for all inpatient cases ranging from moderate to high complexity (i.e. trauma, invasive cardiac, multiple procedures, etc); using the current version of ICD-CM Classification for Hospitals to arrive at the most appropriate DRG assignment. Coder must have key inpatient coding knowledge and experience necessary to determine the correct principal diagnosis, identifying and assigning co-morbidities and complications, major co-morbidities and complications, secondary diagnoses, present on admission indicators, HAC (Hospital Acquired conditions), principal procedure codes and secondary procedure codes. Coder is also responsible selecting the appropriate DRG and Discharge Disposition code. Queries physicians appropriately when documentation is not clear or straightforward and sends to HIM Operations for follow-up. Other responsibilities include modifier assignments and completing various fields on the computerized abstract. The coder works under minimal supervision. This position requires analysis and critical attention to detail. Internal contacts are primarily within the work group, with close collaboration with the Clinical Documentation Improvement Specialist group. External contacts may include physicians, but are limited and infrequent.

Minimum Requirements
Three (3) years experience hospital coding required
Two (2) years experience coding hospital inpatient strongly preferred

Education/Licenses/Certifications
Associates Degree required (CAHIIM accredited program preferred)
Coding certification required: RHIT, RHIA, or CCS

*Five years experience in hospital inpatient coding plus a CPC-H Certificate may be substituted for education and experience requirements listed above.
Additional Information

Preferred certification for hospital coding is RHIT, RHIA, or CCS; all other listed certification will be taken into consideration with application

Job description
Outpatient Medical Coder
Outpatient Medical Coding job involves coding charts for patients who are treated and released within 24 hours (physician offices, one-day surgery etc.). Outpatient Medical Coders use Current Procedural Terminology (CPT) coding system; however, they must also have a working knowledge of NCCI edits, ICD-9-CM Volume 3, ICD-10 (Diagnostic Codes) and HCPCS (Medicaid and Medicare) Level II codes.
Daily tasks usually include:
• Review patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation and discharge summaries to support codes selected for billing.
• Utilize ICD-9-CM to select the diagnosis-related group (DRG) assignments for each case.
• Identify mistakes in reports.
• Enter coding information into electronic billing system.
Primarily, Outpatient Medical Coders work with physicians’ offices, community and out-patient clinics and out-patient hospitals. Outpatient Medical Coders work regular office hours and they may work off-site from their homes.
Training:
• High school diploma.
• Completion of an accredited medical coding program.
• Must be familiar with standard types of abstracting and encoder systems.
• AHIMA Certification: CCS-P (Certified Coding Specialist – Physician).
• AAPC Certification: CPC (Certified Professional Coder).