Inpatient Coder

Job Summary

Under direct supervision, the Inpatient Coder is responsible for the accurate coding and abstracting of inpatient cases or services (diagnosis, conditions and procedures) from medical record documentation. Assign codes and modifiers using the appropriate version of ICD-CM, ICD-PCS, CPT and HCPCS as well as other specialty systems as required by diagnostic category. The Inpatient Coder is expected to code and abstract Observation (OBS), Hospital Ambulatory Surgery (HAS), Emergency Department (ED), and complex Hospital Outpatient Visit (CHOY) services when needed.

All work must be performed in accordance with the rules, regulations and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, ICD-PCS, CPT and HCPCS code book, CPT Assistant, NCCI Edits, CMS, OSHPD and Kaiser Permanentes organizational and institutional coding guidelines.

Essential Responsibilities

• Coding and Abstracting: Reviews medical record documentation to identify diagnoses/procedures to be coded.
• Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
• Codes all appropriate diagnosis and procedures from the medical record using ICD-CM, ICD-PCS, CPT and HCSPCS coding classification systems.
• Responsible for the sequencing of diagnoses and procedures in accordance with guidelines outlined in ICD-CM, ICD-PCS, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems.
• Determines that the DRG is appropriate for each case and reviews DRG discrepancies to ensure appropriate group of each case.
• Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting.
• Corrects data when needed.
• Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS and regional and local KP policies.
• Ensures the accuracy and integrity of data abstracted and coded based upon medical record documentation prior to data submission or coding completion.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
• Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
• Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.
• Demonstrates knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
• Other Duties: Performs other duties as assigned.

Grade: 650