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

The coder/abstracter is responsible for accurate code assignment of all inpatient, outpatient, and emergency service diagnoses, procedures, and conditions as indicated in the patient medical record.

Classification systems include ICD-10 and CPT editions, and all coding is performed in accordance with official coding guidelines from the American Medical Association, the American Hospital Association, and the American Health Information Management Association. All work follows Revenue Cycle Department and MUSC approved policies and procedures.

Must have coding credential from AAPC or AHIMA.

Associate’s degree in health information technology or related field or 5 years coding experience; coding certification (e.g., CPC, CCS) required.

With Associate’s degree, minimum of 2-3 years of experience in coding and familiarity with coding software.

Strong analytical skills and ability to resolve coding issues.

Effective communication and interpersonal skills.

Required certifications: RHIT, CCS, CCA, CPC, CPC-A, or other coding credential.

The Medical University of South Carolina is an Equal Opportunity Employer that participates in the federal E-Verify program.

Coder II-5