At Houston Methodist, 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.
Key Responsibilities
- Assign accurate ICD-10-CM and ICD-10-PCS codes using an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
- Review medical record documentation and abstract data into the encoder and EPIC/EHR to determine principal or final diagnosis, co-morbid conditions, complications, secondary conditions, and procedures.
- Review discharge disposition data and correct abstracted information as needed.
- Enter physician identification numbers and procedure dates correctly in the medical record abstracting system.
- Respond to requests to code or review coded accounts for accuracy.
- Initiate physician queries when diagnoses and/or procedures need clarification.
- Maintain coding productivity and quality standards while meeting departmental coding timeframes.
- Support organizational goals related to accounts receivable for uncoded accounts.
- Participate in coding meetings and education sessions and contribute to process and quality improvements.
Requirements & Qualifications
Qualifications
- Associate’s degree or higher in a CAHIIM-accredited program, or an additional two years of relevant experience in lieu of degree.
- One year of relevant inpatient coding experience, or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program.
- One of the following certifications is required:
- RHIT (Registered Health Information Technician)
- RHIA (Registered Health Information Administrator)
- CCS (Certified Coding Specialist)
- Knowledge of coding classification systems, DRG and APC systems, official coding guidelines, and coding compliance.
- Working knowledge of medical terminology, anatomy, and physiology.
- Proficiency with electronic encoder applications preferred.
- Knowledge of electronic medical record and imaging systems preferred.
- Strong PC skills and ability to work with office software, coding software, and abstracting systems.
- Strong English communication skills for speaking, reading, and writing.
- Ability to communicate effectively with patients, physicians, family members, and co-workers.
- Must comply with AHIMA Standards of Ethical Coding.
Location
Houston, Texas, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
3 weeks ago
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