Inpatient Coder

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The Inpatient Coder is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based on documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines.

FLSA Status: Non-exempt

Essential Functions

• Interacts and communicates effectively with members of the coding team and appropriate stakeholders.
• Participates in coding section meetings and coding education in-services, provides feedback, assists others, and shares knowledge.
• Responds promptly to internal and external customer requests, including requests to code or review coded accounts for accuracy.
• Initiates physician queries to obtain or clarify diagnoses and/or procedures as appropriate.
• Assigns accurate ICD-10-CM and ICD-10-PCS codes using an electronic encoder application in accordance with hospital policy and regulatory guidelines.
• Reviews medical record documentation and abstracts data into the encoder and EPIC/EHR to determine principal or final diagnosis, co-morbid conditions, complications, secondary conditions, and procedures.
• Maintains department standards for abstracting quality, including reviewing discharge disposition and correcting data when necessary.
• Complies with the Standards of Ethical Coding set forth by AHIMA and adheres to official guidelines.
• Maintains coding productivity and timeliness standards while supporting accounts receivable goals for uncoded accounts.
• Reviews assigned work queues and processes items in a timely manner.
• Evaluates personal performance, accepts feedback, and contributes ideas to improve coding and abstracting quality.

Work Requirements

• Business professional attire required.
• No on-call requirement listed.
• May require travel within and outside the Houston metropolitan area.