Job Description - Pro Fee Coder – Hospitalist 

The Pro Fee Coder – Hospitalist will review clinical documentation to assign and sequence diagnostic and procedural codes for hospital-based inpatient and observation encounters to meet the requirements of physician billing and reimbursement. This role focuses on professional fee (pro-fee) coding for hospitalists, ensuring accurate Evaluation & Management (E/M) coding for initial, subsequent, and discharge visits, as well as compliant documentation to support medical necessity and coding integrity. The Coder performs documentation review and assessment for accurate abstracting of clinical data and may interact with providers and clinical staff for clarification and education.

DUTIES AND RESPONSIBILITIES:

• Select and assign ICD-10-CM and CPT/HCPCS codes for hospitalist services, including:
  • Initial hospital care
  • Subsequent daily visits
  • Discharge management
  • Observation and admission-to-discharge same-day encounters
  • Critical care services (as applicable)
• Review and analyze provider documentation to ensure accurate E/M code selection based on time, complexity, and medical decision-making.
• Identify and resolve documentation gaps through provider queries and clarification when necessary.
• Ensure compliance with Medicare, Medicaid, and commercial payer guidelines for inpatient professional coding.
• Validate that diagnoses and documentation accurately reflect patient acuity and severity of illness (SOI) and risk of mortality (ROM).
• Maintain knowledge of split/shared and teaching physician guidelines applicable to inpatient settings.
• Abstract key data elements from the medical record to ensure accuracy, completeness, and quality of coded data.
• Collaborate with the client team and other coders to ensure consistency, accuracy, and adherence to quality standards.
• Maintain strict patient and provider confidentiality in compliance with HIPAA and regulatory standards.
• Participate in Savista and client staff meetings, trainings, and continuing education sessions as required.

SKILLS AND QUALIFICATIONS:

• Required:
  • Active AHIMA (RHIA, RHIT, CCS, CCA) or AAPC (CPC, COC, CCS-P, or related specialty) credential.
  • Two or more years of recent hands-on coding experience in hospitalist, inpatient professional, or observation services.
  • Strong understanding of E/M leveling, time-based coding, and medical decision-making for hospital-based encounters.
  • Familiarity with split/shared visits, teaching physician documentation, and inpatient medical necessity requirements.
  • Proficiency in ICD-10-CM and CPT/HCPCS code sets and official coding guidelines.
  • Ability to code at 95% accuracy or higher while maintaining production standards.
  • Proficient in MS Office applications (Word, Excel, Outlook) and EHR systems such as Cerner, Epic, or similar.

PREFERRED SKILLS:

• Prior experience coding for hospitalist groups, internal medicine, or inpatient acute care settings preferred.
• Associate degree in Health Information Management (HIM) or a related field, or equivalent education and experience.
• Familiarity with RCX, Cerner, 3M, or NextGen systems (a plus).
• Experience coding high-volume hospitalist charts and communicating with providers for documentation improvement.
• Understanding of HCC and risk adjustment capture for inpatient coding.