The Coder III is responsible for performing International Classification of Diseases (ICD) coding of all inpatient charts for billing, case mix, and data collection purposes and subsequently assigns Diagnostic Related Groups (DRG). The Coder III completes retrospective review of patient charts and performs edits to resolve errors. The Coder III maintains data integrity within the hospital information systems.
Responsibilities
- Assigns ICD codes to patient diagnoses and procedures for inpatient services
- Assess the accuracy and completeness of all information provided in documentation
- Assign codes to diagnosis, procedures, and treatments in accordance with prescribed classification systems
- Assigns Diagnostic Related Groups to inpatient encounters
- Enter relevant patient data such as active medical complaint, the reason for admission, type of illness, and breakdown of treatment provided
- Review provider documentation to determine the principal and secondary diagnosis and co-morbidities and complications
- Use technical coding principles and reimbursement expertise to assign proper diagnosis and procedures to each patient record
- Prioritizes assignments according to established criteria and decrease pending accounts
- Contacts or queries physician when additional information or clarification is needed to code
- Reviews documentation and coding for accuracy and practices compliance with coding guidelines and protocols
- Performs compliance edits on inpatient records, and ensures discrepancies are resolved
- Reviews abstracted and statistical data for corrections and submits findings to leader
- Maintain current information/knowledge regarding coding principles and guidelines
- Completes retrospective reviews on patient charts as requested
- Assists in peer reviews on designated patient charts by utilizing established guidelines
- Utilizes the Electronic Health Record system and other related computer systems and software
- Selects appropriate assignments for coding/abstracting from work queues
- Enters coded and abstracted data appropriately for use within the hospital information system
- Assigns appropriate discharge disposition to patient encounters
- Maintains data integrity through review of the overall completeness, accuracy, and consistency of data within relevant systems
Qualifications
Education:
Certification:
- CPC and/or CPC-H, CCS, RHIT, and/or RHIA
Experience:
- 4 years as a medical coder in a hospital setting
Skills:
- Analyzing and organizing technical data
- Multitasking, time-management, and organization
- Verbal and written communication
