Coder - Inpatient

The inpatient coder is responsible for the assignment of accurate and complete International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedure Coding System (HCPCS) codes and modifiers for inpatient visits is essential to the hospital’s cash flow. The inpatient coder is responsible for performing complex technical duties with a high degree of accuracy and at a fast pace. The inpatient coder uses the current approved protocols and an electronic encoder for assignment of numerical rubrics to medical conditions, surgical, diagnostic and therapeutic procedures to optimize the hospital’s data collection and reimbursement. The inpatient coder is also responsible for tracking and abstracting of data for certain cancer, e.g., cancer, trauma, maternal, infant and physician. This position requires knowledge of federal regulations, state requirements, compliance regulations and HFAP (Healthcare Facilities Accreditation Program) standards. This position requires one of the following: from AHIMA: CCS, RHIT, RHIA, or from AAPC: CIC

  • Reads a medical record to discern the underlying clinical condition that was the result of the hospitalization or encounter.
  • Applies knowledge of the conventions, rules and guidelines of multiple classification systems to accurately code diagnoses and services.
  • Assigns current ICD, CPT, and HCPCS codes and modifiers with acceptable accuracy, using an electronic encoder system for all the various types of inpatient and outpatient visits. 
  • Proficient code assignments on both inpatient and outpatient visits are the primary duties of this position.
  • Codes will be assigned for the following:
    • Admitting diagnosis.
    • Principal diagnosis/reason for visit.
    • Secondary diagnosis as applicable.
    • Principal procedure.
    • Secondary procedures, as applicable (diagnostic and therapeutic)
    • Other services (diagnostic and therapeutic).
  • Identifies and abstracts data per predetermined protocols for certain cases.
  • Translates medical record documentation to accurate and complete code(s), according to industry approved guidelines, department policies, productivity standards and quality expectations.
  • Keeps abreast of coding protocols and changes, as documented by approved agencies such as:
    • American Hospital Association
    • American Health Information Management Association
    • Health Care Financing Administration
    • National Center for Health Statistics
    • American Medical Association
    • State agencies
  • Abides by the compliance plans of Mercy Hospital & Medical Center and the Health Information Management Department.
  • Communicates with doctors for clarification of documentation, as needed.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.