Under the direct supervision of the Hospital Coding Supervisor, the Coder II is responsible for abstracting and coding medical record documentation across multiple departments, including inpatient, outpatient, clinic, and emergency services. This involves selecting and sequencing appropriate ICD-10-CM/PCS, HCPCS, and CPT-4 codes to ensure accuracy and compliance with coding guidelines. The role contributes to coding compliance by ensuring timely and accurate code assignment for diagnoses and procedures, including final DRG assignment.

The coder/abstracter assigns accurate codes for inpatient, outpatient, and emergency service diagnoses, procedures, and conditions based on patient medical records. Coding uses classification systems including ICD-10 and CPT editions, following official coding guidelines from AMA, AHA, and AHIMA, and adheres to Revenue Cycle Department and MUSC policies.

Candidates must have coding credentials from AAPC or AHIMA and meet qualifications including an associate's degree in health information technology or related field, or five years of coding experience with certification (e.g., CPC, CCS). A minimum of 2-3 years of coding experience and familiarity with coding software is required for those with an associate's degree. Strong analytical, communication, and interpersonal skills are essential.

Certifications required include RHIT, CCS, CCA, CPC, CPC-A, or other coding credentials.

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