Hospital Inpatient Coder

Working under the general direction of a coding supervisor, the Hospital Inpatient Coder is responsible for the assignment of ICD-10-CM and ICD-10-PCS codes by reviewing all appropriate documentation in accordance with standard coding guidelines. The Facility Inpatient Coder identifies the principal diagnosis, comorbidities/complications, present on admission indicators, and determines sequencing of codes to calculate the most appropriate DRG representing the patient stay. The role maintains knowledge of both Medicare Severity Diagnosis Related Groups (MS-DRG) and All Patient Refined Diagnosis Related Groups (APR-DRG) is required. Additionally, the incumbents maintain knowledge of appropriate capture of codes for statistical purposes such as Social Determinants of Health (SDOH), Hierarchical Conditions (HCC), and severity impacting conditions.

Reviews medical documentation/health information within various electronic medical/health system(s) and assigns applicable codes (ICD-10-CM, ICD-10-PCS) within productivity and quality standard for area(s) of assignment/specialty (Facility or Professional).

Abstracts all required data elements for reporting and statistical capture in a timely and accurate manner into the applicable system using the applications appropriate to the work assignment. This may include but not limited to: EPIC (CS-Link), EPIC HB and PB modules, Solventum 360Encompass, Solventum Standalone Encoder, Select Coder, etc.

Applies basic knowledge of industry requirements of specific category coding and the impact (SDOH, PSI).

Resolves complex inpatient edits/alerts with consistent accuracy using current guidelines within area(s) of assignment/specialty

Communicates with Clinical Documentation Integrity Team members regarding complex clinical scenarios to ensure all relevant codes are assigned

Focuses learning on advanced level concepts

Translates medical records/health information including diagnoses, procedures and treatment and assigns standardized codes (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), International Classification of Diseases, Tenth Revision, and Procedure Coding System (ICD-10-PCS) for patients receiving services within the Cedars Sinai Health System and its affiliates.