Medical Records Technician (Coder Inpatient)

About the role

Inpatient (Coder) select codes from current versions of ICD CM, PCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes.

Responsibilities

• Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• Comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services.
• Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected, when necessary. Correct any identified data errors or inconsistencies. Ensure audit findings have been corrected and refiled.
• Use various computer applications to abstract records, assign codes, and record and transmit data.

Requirements

• Must be proficient in written and spoken English.
• Must be able to perform essential functions of the job with or without reasonable accommodation.

Qualifications

• Bachelor's degree from accredited college or university.
• One year creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities (KSAs):
  • Ability to use health information technology and various office software products used in MRT (Coder) positions.
  • Ability to navigate through and abstract pertinent information from health records.
  • Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and reporting.
  • Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation.
  • Knowledge of The Joint Commission requirements CMS and/or health record documentation guidelines.
  • Ability to manage priorities and work to complete duties within the required timeframes and the ability to follow-up on pending issues.