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Inpatient Coders

Epic, 3M 360 Encompass System, Availity Systems

Reviews and interprets physician documentation to appropriately assign diagnosis and procedure codes.

• Communicates with and provides feedback to the education team and/or providers.

• Reviews patient charges to determine necessary coding to complete the account.

• Identifies principle and secondary diagnoses as well as procedure codes from the electronic medical record.

• Utilizes the encoder or coding books to generate ICD-10-CM, ICD-10-PCS, and CPT codes for diagnosis and procedures.

• Sequences diagnosis and procedures to generate appropriate billing.

• Queries physicians to obtain diagnosis if not clearly provided in records.

• Utilizes other available resources for assignment of codes as necessary (e.g., Epic, MIQS, Cardio IMS, and coding reference materials).

• Assists other coders in resolving coding problems.

• Provides ICD-10 and CPT, for physician research projects, and for quality reporting purposes.

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