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The coder abstracts clinical information from medical records to assign accurate ICD-10 and CPT codes for inpatient and ambulatory surgery. They also ensure coding accuracy, manage DRG assignments, and collaborate with the HIM department to maintain high-quality documentation.
The Medical Coder 3 (inpatient and ambulatory surgery) abstracts clinical information from a variety of medical records, charts and documents and assigns appropriate ICD-10 - CM/PCS and CPT codes to patient records according to established procedures. Works with coding databases and confirms DRG assignments. Familiar with standard concepts, practices, and procedures within a particular field. Relies on instructions and pre-established guidelines to perform the functions of the job. This position relies on guidelines and some experience and judgment to complete job and works under general supervision.
Experience - RHIT/RHIA plus 5 years of acute care coding experience, or RHIT/RHIA with ICD-10 curriculum plus 3 years of acute care coding experience, or 7 years acute care coding experience; CCS substitutes for 1 year of acute care coding experience
Education - High School or equivalent
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