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Inpatient Coder-CCS with 5 years acute care inpatient coding experience
reviews clinical documentation and diagnostic results and applies appropriate ICD-10-CM, and
CPT-4 codes. Codes are used for billing, internal and external reporting, research and regulatory
compliance activities. Resolves billing related errors and assists with workflow changes and process
improvement projects. Meets ongoing productivity and quality standard of 95% accuracy rate or better.
Verifies that all ICD-10 codes are correctly captured. Verifies that physician is correctly abstracted. Keeps
abreast of coding guideline changes. May identify chargeable items for facility level for given department.
May assign codes for diagnoses and treatment for ancillary outpatient encounters. Abides by the
standards of Ethical Coding as set forth by the American Health Information Management Association
(AHIMA) and adheres to all official coding guidelines. Performs other duties as assigned.
Additionally, the Coder III utilizes technical coding principles and APC reimbursement expertise to assign
appropriate ICD-10-CM and CPt-4 procedures. Assigns codes for diagnoses, treatment and procedure for
multiple specialized departments, including Outpatient ancillary, Emergency Department, and Inpatient and
Outpatient Surgery. Determines the correct principal diagnosis, co-morbidities, complications, secondary
conditions and surgical procedures. Assigns MS-DRG, Present on Admission (POA) indicators, Hospital
Acquired conditions), and accurately abstracts discharge dispositions. Queries physicians per established
policy and procedure when documentation is not clear or conflicting.