Inpatient Coder—Hospital Sample Position Description Position Title: Inpatient Coder—Hospital Reports to: Director of Health Information Management, Manager—Clinical Coding, or Manager—Medical Record Services Summary: Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-9-CM codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the director of Health Information Management, manager—Clinical Coding, or manager—Medical Record Services, accurately code inpatient conditions and procedures as documented in the ICD-9-CM Official Guidelines for Coding and Reporting. Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors. Responsibilities: Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for inpatient encounters. Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures. Utilizes technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-9-CM diagnoses and procedures. Assigns present on admission (POA) value for inpatient diagnoses. Extracts required information from source documentation and enters into encoder and abstracting system. Identifies non-payment conditions (HAC) and when required, report through established procedures. Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines. Qualifications: Minimum of successful completion of an AHIMA-approved Coding Certificate Program. Associate’s degree or equivalent training acquired through at least two years of progressive on-the-job experience. RHIA, RHIT, or CCS certification status preferred.