Tufts Medical Center Inpatient Coder/Coder II in Boston, Massachusetts
Inpatient Coder/Coder II
Department: Health Information Management
Schedule: Full-Time Regular
Shift: Day shift
Associate's degree is preferred
1-2 years experience is required
Under the general direction of the Coding Manager, this position reviews the medical record to verify diagnosis and procedures and Present on Admission Indicators. The Coder abstracts the information by using the appropriate coding classification system. Verifies codes for statistical and reimbursement purposes. Responsibilities: Performs a complete chart review. Assigns ICD-9 CM and/or CPT codes in accordance with coding and reimbursement guidelines. Assists in obtaining final diagnosis and contacting physicians for clarification of documentation when needed. Verifies and abstracts specific clinical and demographic data: 1. Discharge disposition 2. Transfer destination 3. Date and responsible party for all procedures. Verifies the DRG assignment, paying special attention to DRG's in which a comorbid condition or complication has been identified. Inputs the appropriate information into the hospital system discharge abstract. Refers appropriate charts for DRG Validation, prints the coding sheets and attaches it to the record for review based on Departmental Policy. Performs related duties such as answering and routing telephone calls and receiving people requesting information and services in the department. Assists in the implementation of the ICD-10 Coding Classification system. Trains clinic staff on the use of ICD-10 codes. Assists in training of new staff. Reconciles daily Inpatient reports and provides weekly feedback to Department Management Performs or assists with other duties assigned by the Coding Manager. Requirements: Working knowledge of ICD-9-CM and CPT coding system, DRG, APG, payment systems, medical terminology, anatomy and physiology. Excellent organizational and communication skills. Working knowledge of computers preferred Completion of coding certificate program required. RHIT/RHIA or CCS required.