Hussien M. Hassen
Western Governors University
Coders who work in inpatient healthcare facilities collect data from the patient record and assign appropriate codes to inpatient diagnosis, procedures, and abstract information according to the current standard classification systems. Inpatient coders understand the health organization’s rules, the prevailing government regulations, and the documentation standards. Effective communication skills are crucial to communicating with physicians and nurses. A comprehensive applicable coding knowledge enables the coder establish the diagnosis of diseases, procedures, outcomes, and complications from provider documentation (AHIMA, 2008). The professional coder understands the nature of events in an inpatient environment, including hospital induced conditions, such as nosocomial infections, and interprets them into accurate codes for billing, medical research, and statistics.
Inpatient coders can specify related diagnosis codes for inpatient records, such as secondary diagnosis and the existence of concurrent morbidities. The professional coder quickly adopts and identifies disease and procedure codes and groups them into the diagnosis related group (DRG) codes and then captures present on admission (POA) indicators for all cases of inpatient admissions, as well as the discharge condition codes as required (Genna, 2009) The coder can relate the procedures and diagnosis based on the current coding classifications standards, such as International Disease Classifications (ICD) and DRG codes based on the organization’s coding rules.
Inpatient coders communicate efficiently and with clarity. They must avoid mistakes, such as incorrectly wording queries that may challenge a physician’s authority in selecting the correct diagnosis. The coders dedicate their interpersonal communication skills to putting forward queries that support improvement in documentation and revenue...