Medical Records Technician (Coder Inpatient)

Basic Functions: Selects and assigns codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Uses various computer applications to abstract records, assign codes, and record and transmit data. Codes all complicated and complex medical/specialty disease processes, patinet injuries, and all medical procedures in a wide range of inpatient setings and specialties. Reviews provider health record documentation to ensure it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Performs a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. Independently reviews and abstracts clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Abstracts, assigns, and sequences codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Queries clinical staff with documentation requirements to support the coding process. Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies. Ensures audit findings have been corrected and refiled. Work Schedule: 8:00 am- 4:30 pm; Monday- Friday (negotiable) Telework: Available - per agency policy Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized