Inpatient Coder
- Coding and Abstracting: Reviews medical record documentation to identify diagnoses/procedures to be coded.
- Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
- Codes all appropriate diagnosis and procedures from the medical record using ICD-CM, ICD-PCS, CPT and HCSPCS coding classification systems.
- Responsible for the sequencing of diagnoses and procedures in accordance with guidelines outlined in ICD-CM, ICD-PCS, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems.
- Determines that the DRG is appropriate for each case and reviews DRG discrepancies to ensure appropriate group of each case.
- Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting.
- Corrects data when needed.
- Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS and regional and local KP policies.
- Ensures the accuracy and integrity of data abstracted and coded based upon medical record documentation prior to data submission or coding completion.
- Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
- Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
- Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
- Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
- Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.
- Demonstrates knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
- Other Duties: Performs other duties as assigned.
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