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Coder / Abstractor IV (541) 

Category Health Information Services - 7180  

JOB SUMMARY: Abstracts clinical information from medical records. Assigns appropriate ICD-10-CM and CPT-4 codes.



  • Must be CCS Certified with a minimum of 3 year's hospital coding experience or equivalent.
  • Assigns ICD-10-CM and CPT-4 codes in accordance with coding and reimbursement guidelines including, but not limited to, the following:
    • Identifies principal and secondary diagnoses and procedures based upon UHDDS standards.
    • Uses seventh character and sequencing conventions.
    • Documentation is present to substantiate codes assigned.
  • Abstracts relevant clinical and demographic information from the medical record.
  • Maintains a control system to assure completeness of the indexing system; enters all corrections in response to system edits and internal controls. Serves as a coding resource for Patient Financial Services.
  • Refers coding and system questions to the supervisor/Director in a timely manner for determination and guideline development.
  • Assists in abstracting and retrieval of data for selected studies requested by Clinical Excellence.
  • Keeps current on coding guidelines, rules and regulations, and new codes. G. Remote coding agreement signed and approved by Director. H. Other duties as assigned.


  • Accuracy:
    • Accurately codes all diagnoses and procedures measured by Coding Quality Audits: 97 percent of all records for which the employee is responsible must be coded accurately to maximize DRG/APC weight.
  • Productivity Level:
    • Laboratory/Radiology coding: 2 minutes/record;
    • Provider Office Visits: 2 minutes/record;
    • Wound Professional Accounts: 2 minutes/record;
    • Recurring Patient Visits: 3 minutes/record;
    • ED/Urgent Care coding: 5 minutes/record;
    • Wound Clinic Accounts: 5 minutes/record;
    • Recurring Oncology: 5 minutes/record;
    • Outpatient Surgery and Short Stay coding: 12 minutes/record;
    • Peripheral vascular coding: 20 minutes/record; Non-CCS Inpatient coding: 20 minutes/record.
  • Productivity Calculation:
    • Laboratory/Radiology coding: 2 mins/record x__________ charts;
    • RCR coding: 3 mins/record x__________ charts;
    • ED/Wound Clinic coding: 5 mins/record x__________ charts;
    • Recurring Oncology: 5 mins/record x__________ charts;
    • SDC/INO: 12 min/record x__________ charts;
    • Inpatient: 20 min/record x __________ charts.
  • Using productivity levels above, calculate hours produced and divide by hours worked. 95 - 100 percent - 2; 80 - 94.99 percent - 1; <80 percent - 0;
  • Abstracted information and codes are accurately keyed into the computer abstracting system. 97-100 percent - 2; 90-96.99 percent - 1; <90 percent - 0.
  • Coded accounts are monitored to assure required fields for each patient type are consistent and complete.
  • Corrects appropriate coding and abstracting discrepancies.
  • Assists Patient Financial Services in clarification of coding vs. reimbursement issues.
  • Seeks assistance only after referring to own resources.
  • Keys abstracted information for selected studies when applicable.
  • Assures accuracy of all abstracted information.
  • Generates reports as requested.
  • Demonstrates ability to embrace and adapt to change.
  • Regularly initiates ideas to improve the efficiency and processes of the department in a positive and productive manner by attending at least 90 percent of monthly departmental meetings.
  • Keeps current on coding guidelines, rules and regulations, and new codes.
  • Maintains productivity and accuracy standards in order to continue remote coding privileges.
Position Requirements


  • Certified Clinical Coder (CCS) required. Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) accepted if CCS certified. Clinical Documentation Improvement Specialist preferred.
  • Working knowledge of the ICD-10-CM and CPT-4 coding systems, medical terminology, anatomy and physiology.
  • Experience in computer operations.
  • A minimum of three (3) years hospital coding experience or equivalent.
  • Types accurately at least 30 WPM.
  • Mandatory Continuing Education: Customer Service, Fire and Safety, Corporate Compliance (including Confidentiality), Infection Control, and education required by regulatory, accreditation bodies, scope of practice, and/or Hancock Regional Hospital.
Full-Time/Part-Time Full-Time  
Shift -not applicable-  
Sign-On Bonus  
Position Coder / Abstractor IV (541)  
Number of Openings 1  
Exempt/Non-Exempt Non-Exempt  
Open Date 11/1/2019  
Location Hancock Regional Hospital  
About the Organization Hancock Regional Hospital serves Hancock County and the surrounding areas as a full-service community hospital focused on primary care, patient comfort, and convenience.

Today, a highly skilled medical and professional nursing staff anchors Hancock Regional Hospital. We have a state-of-the-art surgery department, 24-hour emergency services, OB services, progressive and critical care, a geropsychology unit, home healthcare, occupational health, a transitional care unit, a total oncology program with a cutting-edge radiation oncology center, many private rooms, and a full complement of Inpatient and outpatient services.

Our Mission is to be a Caring Community Partner by healing, improving health and wellness, alleviating suffering, and delivering acts of kindness one person at a time.  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.  

This position is currently not accepting applications.

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