Job Description Report. r Job Inpatient r

 As a managerial health care professional, an Inpatient r is responsible for reviewing and organizing allpatient files for accuracy, and coding that information into the computer system so that the records will indicate all relevant data, such as the reason that the patient was admitted, type of illness and breakdown of the treatment that was prescribed and received. Some examples of how the Inpatient Coder is required to do the coding are:

Guidelines: Follows official coding guidelines to review and analyze health records.

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Feedback: Provides feedback and education to physician and professional staff regarding changes in coding methodology and enhanced documentation procedures for optimizing reimbursement.

Billing etc: Coders who also serve as billers must be familiar with the physician’s personal fee schedule, the Hospital charges and packages etc. They should also know how to record and account for reimbursements and use the billing software and use the indices in all the coding books effectively.

Software: They should be competent in using Medical Coding ICD-9 Software. This is a&nbsp.diagnosis&nbsp.and&nbsp.procedure&nbsp.categorization search tool based on the latest&nbsp..NET&nbsp.Framework Technology.&nbsp.Adding, modifying or deleting ICD-9-CM codes with the click of a mouse.

Chart Review: An inpatient coder must thoroughly review all patient medical charts in an effort to ensure that all information is accurate and reliable. He should do chart review by extracting pertinent data from the patient’s health record, and determine appropriate coding for reports and billing documents.

Compliance: All information entered into the database by an inpatient coder must be done so in accordance with the policies and procedures of the medical facility. Should Maintain compliance with both external regulatory and accreditation requirements, and with State and Federal regulations.

Staff Interaction: When discrepancies and other anomalies are discovered in files, an inpatient coder must communicate with medical staff members such as nurses and doctors to resolve the issue immediately without delay.

Education: In order to gain employment as an inpatient coder, the candidate must possess a high school diploma or its equivalent and have taken coursework in medical terminology, physiology and anatomy.

Coding for Hospice Care: Hospice Care typically work to maintain the comfort and maximize the quality of life of fatally ill patients.

On admission, the coder must identify and code the diagnosis that qualifies the patient to meet the hospice certification of “life expectancy of 6 months or less”. During the hospice episode, the additional disorders/diseases may be added and should be updated upon recertification.

End-stage diagnoses are not usually captured by the ICD-9-CM code( the medical coding software). Secondary diagnoses also are coded because patients other have multiple medical conditions at the end of life. Eligibility criteria by diagnosis is guided by the LCD. (Example: End Stage Heart Failure is characterized when the patient already has been optimally treated for heart disease). Hospice coders should be familiar with these criteria to determine appropriate coding of terminal diagnosis and co morbidities.

Example of an ad:

Coder Job Description: Outpatient Coder:

An outpatient coder must know how to code multiple areas efficiently, related to the services performed at an outpatient hospital or a hospital owned facility that is classified as outpatient. The types of coding this type of coder must know are CPT procedures, ICD-9 diagnosis codes, and HCPCS supply and service coding. A coder must know medical terminology and anatomy.

Outpatient Coder would be responsible for abstracting, coding, and sequencing the classification of medical and surgical procedures, professional services, diagnosis, supplies and treatment modalities. Some of the core tasks are:

Selection: He should selects the most accurate and descriptive codes from the listings of American Medical Association Current Procedural Terminology (CPT-4) Coding system, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). and Healthcare Common Procedure Coding System (HCPCS).

Assigning and Complying: Assigns Diagnosis-Related Groups (DRGs) and performs coding compliance reviews. Abstracts and codes pertinent medical data into multiple software programs.

Daily Activities: An outpatient coder must determine the most appropriate coding from either a paper chart record or an electronic chart record.

Computer Software Used: Most facilities have a specific type of computer software the coder uses to determine the Ambulatory Payment Classification (APC) used by government payors and many third-party insurance carriers.

Ability to Override: The Outpatient coder must have a good understanding of when the data does not explain “the whole picture.” They have the ability to override the computer code outcome for more appropriate choices of codes or APC.

Accurate Evaluation: A coder must be able to accurately evaluate when more information is needed from the physician or ordering medical provider.

Confidentiality: Coders must not discuss any medical case outside the office with any other employee, family member or friend.

Example of an ad:


(n.d.). Retrieved 2011, from

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Henderson, K. (2011). Retrieved from

Lou Ann Schraffenberger. (2011). Effective Management of Coding Services. AHIMA Press.

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