CERTIFIED INPATIENT/OUTPATIENT CODER

Certified Inpatient/Outpatient Coder

Primary responsibility is the assignment of ICD-10 and CPT codes for all Inpatient discharges and

all outpatient records in a timely and accurate manner.

DUTIES & RESPONSIBILITIES:

1. Responsible for accurately assigning ICD-10 diagnosis and procedural codes on all Inpatient Discharges and Outpatient records using the 3M Code-finder in a timely manner.
2. Assures the following patient information is correct and properly abstracted in CPSI information system within seven days of patient discharge:
   1. ICD-10-CM Diagnosis and Procedure codes are entered and sequenced properly.  Procedure dates and procedural physician is correctly indicated with procedure code.
   2. DRG’s (Diagnosis Related Groups) are calculated for all Medicare Inpatient discharges.
   3. Discharge Disposition is correct, reflecting physician discharge order on medical record.
   4. Admission type code is correct.
   5. Service is correct.
   6. Physicians are entered and correct with attending physician listed first and subsequent physicians listed after.
3. Assembles and Deficiencies charts according to hospital guidelines.
4. Assists others as needed, or as directed by the Medical Records Director.
5. Keeps Medical Records Director informed as to problems or concerns that hold up or compromise coding process.

WORKING CONDITIONS & PHYSICAL REQUIREMENTS:

1. Well-lighted and well-ventilated, air-conditioned and heated office.
2. The potential for exposure to blood borne pathogens, body fluids, or potentially infectious material is minimal to none.
3. This position requires prolonged periods of sitting with a light amount of physical work.
4. Ability to hear well (hearing device could be used), comprehend and communicate.
5. Visual Acuity must be good (eyeglasses or contacts may be used).
6. Minimal lifting requirements, of 25 pounds.
7. Must have good use of upper extremities.

EDUCATION, TRAINING, AND EXPERIENCE:

Position requires knowledge of medical terminology, anatomy and computer/typing skills.  Experience is preferred but not required.  Requires the ability to decipher physician and nurse orders.

EMPLOYEE TRAITS:

Dependability, confidentiality, ability to type, ability to work with people, must be able to perform more than one task at a time and a person in this position must be able to work well under stress.

WORK RELATIONSHIPS:

Supervised by the Director of Medical Records of the Marshall County Hospital. Must have the ability and willingness to communicate and work well with doctors, department managers, medical offices, and all employees.  Must be willing to help others as needed in the department or as requested by the Director of Medical Records.