Sr. Coder Abstractor - Inpatient

A Day in the Life

• Analyzes each medical record to determine which items will be coded and abstracted.
• Accurately codes and abstracts inpatient medical records, meeting expected productivity standards.
• Sets ICD10-CM diagnosis, ICD10-PCS procedure codes, and CPT-4 procedure codes, following established national and departmental guidelines and the AHIMA Code of Ethics.
• Abstracts and/or edits medical record data as needed by departmental guidelines.
• Assigns and enters charges for ER EM levels, infusions, injections, and procedures according to departmental guidelines.
• Communicates with physicians and Clinical Documentation Integrity Specialists to request clarification and/or additional record information to ensure correct code assignment, appropriate reimbursement, and compliance with established guidelines.
• This includes ICD10 and CPT coding.
• Maintains an organized system for personal coding reference material.
• Participates in educational activities and maintains coding skills.

Qualifications

• Associate's or Bachelor's degree in Health Information, or CCS certification with a minimum of 2 years coding experience may be considered.
• Certification as a Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) is required.
• One to three years' previous experience using ICD10-CM and ICD10-PCS coding systems is required.
• Demonstrated ability to meet productivity and quality standards is required.