Inpatient Certified Coder

Care New England Health System (CNE) and its member institutions is a trusted, integrated health care organization that advances medical research, attracts top specialty-trained doctors, and delivers renowned services and innovative programs.

About the role

The Certified Inpatient Coder ensures accurate coding and abstracting of all inpatient services, procedures, diagnoses, and conditions using appropriate documentation in the medical record. Inpatient services include cardiac care, intensive care, oncology, behavioral health, rehab, and multiple other diagnostic classifications. Classification systems include ICD-10-CM, ICD-10-PCS, and other specialty systems as required.

Responsibilities

• Analyze medical records, extracting clinical, pathological, therapeutic, and epidemiologic data in accordance with established ICD-10-CM coding principles and guidelines.
• Review medical records to identify appropriate diagnoses, procedures, and selection of appropriate DRG.
• Assign diagnosis and procedure codes from all documentation, including procedure notes, operative notes, and consultation notes, using ICD-10-CM and ICD-10-PCS coding classification systems; independently quality-check own work.
• Collaborate and communicate closely with the CDI department.
• Interact with physicians via coding queries to clarify conflicting or ambiguous documentation within the medical record to accurately code patient diagnostic and procedural information.
• Ensure all data abstracted is consistent with guidelines outlined by JCAHO, CMS, regional, and local policy.
• Ensure data is optimally coded for documentation capture, financial reimbursement, care planning, statistics, and regulatory reporting.
• Review medical records to determine accurate required abstracting elements (facility/client-specific elements), including appropriate discharge disposition to ensure accurate reimbursement.
• Demonstrate comprehensive, expert-level knowledge of procedures concerning the sequencing of diagnoses and procedures, including those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines, and other appropriate classification systems.
• Demonstrate knowledge of anatomy, physiology, pharmacology, and pathophysiology to interpret general medical classifications for coding discharge data.
• Ensure timely record availability by meeting established coding and abstracting productivity and accuracy standards.
• Communicate and resolve coding issues around documentation for appropriate follow-up and education.
• Interact and communicate with department lead and manager to clarify and accurately document patient diagnostic and procedural information.
• Maintain and comply with policies and procedures for confidentiality of all patient records.
• Perform other related duties as assigned.

Requirements

• High School diploma or GED required.
• At least three (3) years of hospital inpatient coding experience.
• Certification as a Certified Coding Specialist (CCS).
• Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.
• Coding certification must be maintained on an annual basis.

Skills

• Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance.
• Ability to understand the clinical content of a health record, including the most complicated records.
• Ability to communicate with physicians via a query to clarify diagnoses, procedures, and any other conflicting or ambiguous documentation within the medical record.
• Strong attention to detail and accuracy.
• Adherence to the AHIMA coding code of ethics.
• Ability to maintain department productivity and accuracy standards.