HIM Inpatient Coder (PT, Days)

Website College Medical Center

This position supports the Mission of the Hospital through the provision of distinctive and compassionate care to our patients. This position assigns ICD-10-CM , CPT, and HCPCS codes, creating an APC or DRG group assignments, of diagnoses, surgical and treatment procedures. Abstracts pertinent information from all patient types. Codes and Abstracts chart in a timely manner. Monitors billing status report. Queries physicians. Maintains current knowledge of coding guidelines and reimbursement reporting requirements. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines (CPT assistant and Coding Clinic).

· Coding certification preferred from the American Health Information Management Association or the American Academy of Professional Coders.
· RHIA, RHIT, CCS, CCS-P, CCA, COC certification is required within six months of hire date.
· Ability to pass HIM department coding examination.

· One to Two (1 – 2) years coding experience in an acute care setting.

· Prefer someone with work experience as a coder or strong training background in coding and reimbursement from an AHIMA approved college or university.

· Courses required in Anatomy and Physiology, Pathology and Medical Terminology is required. Working knowledge of hospital computer systems. Detailed oriented. 3M Encoder experience preferred. Completion of an AHIMA approved program for coding (with certificate) or health information technology or administration that is AHIMA approved.


Lifting up to 20 lbs. Bending and stretching. Extended periods of sitting. Frequent hand and wrist movement due to data entry into computer system. Also visual exposure

Frequent exposure to noise, cold and heat. Occasional exposure to bloodborne pathogens, chemicals, general cleaning chemicals.


(All duties listed below are essential to the job.)

* General Staff Accountabilities

  • Employee’s conduct conforms to the Mission, Vision, Values, and Code of Conduct of College Medical Center.
  • Values individual differences and demonstrates sensitivity to the cultural needs of others.
  • Respects the rights, privacy and property of others, and maintains strict confidentiality.
  • Effectively protects all health information from unauthorized access per HIPAA regulations and all applicable local and state laws.
  • Exhibits good attendance and punctuality.
  • Provides appropriate notice prior to vacation/time off and notifies supervisor a minimum of two hours prior to shift when unable to come to work.
  • Observes allotted break and meal periods as prescribed by Hospital Policy and follows time card procedures by accurately writing in and out.
  • Attends to personal affairs to avoid any interference with productivity.
  • Adheres to the Dress Code.
  • Demonstrates an understanding of their personal role in the case of fire/disaster and participates in Performance Improvement activities.
  • Functions with an awareness of patient safety issues and applies basic principles of safety as identified within the facility.
  • Follows the occurrence reporting policy and procedure in reporting any potential safety issues.

* Job Specific Accountabilities

Responsible for coding and/or DRG assignment and/or APC assignment

  • Ensures that records are coded within 3 days of discharge, excluding weekends and holidays.
  • Concurrently reviews inpatient records, using MS-DRG worksheets, looking for accurate and complete physician documentation to support the severity of the patient’s illness and risk of mortality.
  • Participates in concurrent interactions with physicians, nursing, other caregivers and HIM staff to improve quality and completeness of clinical documentation.
  • Actively participates in coding and documentation education for residents and physicians.
  • Queries physician when documentation in record is inadequate, ambiguous, or unclear for coding purposes. Notifies physicians of missing documentation needed to code any record using a professional, tactful manner or “Physician Query” form.
  • Correctly assigns physician query or progress note in computer system.
  • Thoroughly reviews chart to ascertain all diagnoses/procedures.
  • Codes all diagnoses/procedures in accordance to ICD-10CM and PCS coding manuals.
  • Codes procedures with CPT4/HCPCS codes following regulatory requirements.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to coding guidelines (CPT Assistant and Coding Clinic).
  • Uses optimizing screens 3M Encoder to assign the correct DRG/ASC.
  • Utilizes computerized coding and abstracting applications.
  • Consistently demonstrates ability to prioritize workload in a timely manner.
  • Codes and abstracts each chart before going onto the next chart leaving no unfinished charts unless approved by the Director.
  • Actively participates in the Orientation and training and in-servicing of peers (coding staff).
  • Actively participates in coding and documentation education for residents and physicians.
  • Monitors and works on the DNFB billing status report on a daily basis.
  • Notifies the Coding Coordinator whenever working more than 48 hours behind the work deadlines.
  • Assists the Director with state requirements and reports.
  • Assists the Director with quarterly and bi-annual submissions of OSHPD data reports.
  • Applies proper selection and sequencing of secondary diagnosis.
  • Research OP reports for coding of Same Day Surgery charts.
  • Acts as a resource to hospital staff regarding coding questions, changes and issues.
  • Performs all other duties and responsibilities as assigned.
  • Assist in maintaining coding staff scheduling based on volume and facility by notifying director of needs for per-diem coder to come in.
  • Reviews coding periodicals and stays current with coding updates.

Responsible for abstracting data from the medical record

  • Accurately abstracts all procedures performed into the computer system.
  • Accurately abstracts all other information and answering questions in the computer system for each patient visit.
  • Abstracts information from the medical record and enters it into the abstracting application in the electronic health record.
  • Assumes responsibility for cross-checking quality, accuracy and completeness of abstracts.
  • Ensures that each physician that consulted or performed a procedure, attended or admitted the patient is included in the abstract.

Communicates with others.

Respects line of authority by brining issues, concerns and comments, to supervisor before approaching others. Notify supervisor when there is an issue not in the scope of responsibility.

  • Actively participates in the orientation, training, and in-servicing, of peers (coding/CDI staff).

Reports to the Coding/Clinical Documentation Improvement Supervisor if any.

  • Accepts supervisor’s direction and decisions for workflow. Willingly accepts additional assignments.
  • Performs all other duties and responsibilities as assigned.

State Plan / Department Specific Duties and Responsibilities (List all essential duties other than those listed above in order of importance)

o Champions creativity and implements workable new ideas and concepts. Actively seeks opportunities that will add value to the organization. Effectively combines existing knowledge and new ideas to create workable solutions.

Knowledge, Skills and Abilities (List all knowledge, skills and abilities that are necessary to perform the job satisfactorily)

· Pass HIM department coding examination. Medical Terminology knowledge. Understanding of ICD-10 and CPT coding. Detailed oriented. Use of computer.

· Excellent verbal and written communication skills

· Ability to abide by CMC’s policies

· Ability to maintain attendance to support required quality and quantity of work

· Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)

· Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

* Customer Service

· Exhibits behavior that is courteous, compassionate, polite, friendly, and respectful towards patients, visitors, physicians, and co-workers and extends self to make patients, visitors, clinical staff, and peers feel welcome and respected.

To apply for this job please visit www.collegemedicalcenter.com.