Common belief says that if you want to work as a medical coding professional, you can choose between working as an inpatient coder or an outpatient coder. This is true to some extent. However, the best way to become an inpatient coder is to first gain some experience as an outpatient coder. The work of the latter is a little less complex than that of the former. Outpatient coders can get to learn the ropes of working as medical coders with little volume of work. Since outpatient coders are required to close files as soon as a treatment plan is implemented and the patient leaves the facility – which is usually within hours of arriving – the work becomes less complex.
However, inpatient coders have a lot on their hands on a daily basis. They work with records of patients who have been hospitalized, which means that there is constant need to change information in the system – new procedures, additional medication and changing patient conditions are responsible for this. The work of an inpatient coder is to basically assign medical codes to procedures and treatments provided by the facility.
While a high school diploma or a GED is sufficient to work as an inpatient coder, some facilities insist on hiring people who have bachelors’ degrees in health information management. Working at this position requires you to be diligent, accurate and possess great attention to detail, owing to the nature of this work.
Some typical duties that will be entrusted to you in an inpatient coder position include:
• Review patient documentation and assess which information needs to be punched into the database
• Ascertain that all provided patient documentation is accurate by verifying it with staff members
• Punch in relevant patient data such as active medical complaint, reason for admission, type of illness and breakdown of treatment provided
• Assign codes to diagnosis, procedures and treatments in accordance to prescribed classification systems
• Review provider documentation to determine principle and secondary diagnosis and co-morbidities and complications
• Use technical coding principles and reimbursement expertise to assign proper diagnosis and procedures to each patient record
• Identify HACs (non-payment conditions) and ensure that they are properly communicated by utilizing established procedures
• Serve as a contact point for coding related queries
• Ascertain that all data that has been punched into the system is accurate and updated on an as needed basis
• Create each patient record by following strict confidentiality protocols and safeguard data by ensuring that it is stored in a safe manner