Scope of Position

Inpatient coding services assign diagnosis and procedural codes to inpatient medical records to ensure accurate reimbursement, compliance, and data collection for OSU Health System business units.

ICD-10-CM and ICD-10-PCS diagnosis and procedure codes are applied to all inpatient encounters. Medical record abstract data is assigned based on information reviewed for accuracy in IHIS during the coding process.

Position Summary

The Senior Medical Record Coding Specialist – Inpatient is responsible for coding medical records at the conclusion of a patient’s admission. This includes selection of the admitting diagnosis, principal and secondary diagnoses, principal and secondary procedures; assigning accurate ICD-10-CM/PCS codes; sequencing diagnoses and procedures; and abstracting required data elements including admission source, type, disposition, and attending physicians.

This position requires advanced knowledge of inpatient coding guidelines, MS-DRG/APR-DRG grouping logic, and their impact on severity of illness (SOI), risk of mortality (ROM), quality metrics (Vizient, USNWR), and hospital reimbursement. The specialist collaborates with CDI staff, physician advisors, and revenue cycle partners to clarify documentation, support denial prevention strategies, and ensure coding compliance.

Codes are selected using the Computer Assisted Coding/Encoder software following review of the complete electronic medical record. The specialist is responsible for addressing all edits during the coding and abstracting process, ensuring accurate MS-DRG and APR-DRG assignment for compliant hospital reimbursement.

This role must maintain productivity and quality standards set for the department, adhere to assigned work schedules, and submit weekly volume logs.

MINIMUM REQUIRED QUALIFICATIONS

Associate’s Degree in Health Information Management. Credentialed as a Registered Health Information Technician, Registered Health Information Administrator, or Certified Coding Specialist by the American Health Information Management Association. 2 years of relevant experience required. 4-6 years of relevant experience preferred.