Class Specifications - H.45
Health Information Coder IV – 4732
Health Information Coder III – 4733
Health Information Coder II – 4734
Health Information Coder I - 4735
April, 2009
Series Concept
Health Information Coders analyze, abstract, and code in order for the hospital to submit a bill for services rendered and various departments and clinics associated with patient care; perform other related duties as required.
Incumbents typically work under the direction of a Health Information Management professional.
The Coder series consists of four levels with the distinction between levels based on the scope and complexity of the coding functions performed.
Class Concepts
Health Information Coder IV
Under direction of the Assistant Director, incumbent may function as a Lead Inpatient Coder or perform highly complex coding in areas that require specialized expertise. As a lead, incumbent is responsible for daily oversight of the work assignments to ensure optimal workflow and productivity. Responsible for assessing the quality of abstracted data. Acts as a technical and informational resource for the Health Information Coder III level. Provides information on coding question trends, issues that affect the coder-physician communication process and follows up on queries to physicians in order to address coding deficiencies. Reconciles discrepancies between coded physician encounter forms and HIM coding, and works on denials.
As a Specialized Coder, incumbent is responsible for utilizing a highly specialized and complex set of knowledge, skills and appropriate credentials to perform i.e. Interventional Radiology visits).
Health Information Coder III
Under general supervision, incumbents perform abstracting and coding on all inpatient visits at the Medical Center. Assigns appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis and claims processing.
This level may also be used for a lead for outpatient coding, acting as a technical and informational resource for the Health Information Coder I and II levels. Has daily oversight of work assignment to ensure optimal workflow and productivity; performs quality assessments of abstracted data.
Health Information Coder II
Under general supervision, incumbents perform abstracting and coding on all outpatient visits at the Medical Center (including Emergency, Ambulatory Surgery and clinic visits). Applies appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis and claims processing.
Health Information Coder I
Incumbent performs a limited range of coding duties in a training capacity under the supervision of an Assistant Director, coding educator or lead coder while concurrently receiving classroom instruction. Receives training for a period ranging from six months to 18 months to become competent to perform the duties of a Health Information Coder II or Coder III. This is the entry level position.
Minimum Qualifications
Health Information Coder IV
Credentialed as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H). Minimum of five (5) years acute multi-specialty hospital coding experience. Knowledge of ICD-9 CM and CPT coding. Has knowledge of anatomy, physiology, disease process and medical terminology. Able to lead other staff and effectively function as a technical resource.
If acting as a specialist coder, e.g. Interventional Radiology, must have a certification appropriate to the specialty, e.g. CIRC for Interventional Radiology.
Health Information Coder III (Inpatient)
Has one of the following credentials: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT). Successful completion of a twelve (12) month AHIMA approved coding certificate program or twelve (12) months of on the job training AND must obtain coding credential within six (6) months of hire. At least one (1) year of acute hospital coding experience including on the job training. Knowledge of ICD-9 CM and CPT coding. Has knowledge of anatomy, physiology, disease process and medical terminology.
If acting in a lead role, must be able to lead other staff and effectively function as a technical resource.
Health Information Coder II (Outpatient)
Has one of the following credentials: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H). Successful completion of a twelve (12) month AHIMA approved coding certificate program or twelve (12) months of on the job training AND must obtain coding credential within six (6) months of hire. At least six (6) months of acute hospital coding experience including on the job training. Knowledge of ICD-9 CM and CPT coding. Knowledge of anatomy, physiology, disease process and medical terminology.
Health Information Coder I
Has successfully completed a Coding Certificate Program approved by AHIMA. Knowledge of anatomy, physiology, disease process, and medical terminology.