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

Grade: 9

Hours: 8:00am-4:30pm

Job Details:

  • 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: Discharge disposition Transfer destination 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. Participation in continuing education programs as requested by Management Participate in department staff training programs to develop skills that will achieve business goals and foster individual career growth. Assists in the implementation of the ICD-10 Coding Classification system. Trains clinic staff on the use of ICD-10 codes. Reconciles daily Inpatient reports and provides weekly feedback to Department Management Performs or assists with other duties assigned by the Coding Manager. Assists in training of new personnel. Performs other similar and related duties as required or directed. Requirements: Completion of coding certificate program required RHIT/RHIA or CCS preferred, but not required 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