• Review the complete electronic and scanned medical records of discharged patients. Assigns ICD-10-CM diagnosis and ICD-10-PCS procedure codes from documentation in the medical record. • Abstracts coded data and patient information into the coding abstracting system in use by BILH (examples of information include attending physician, surgeon, surgery dates, disposition, discharge date, and infant birth weight). • Applies ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic Advice when coding inpatient records, and facility-specific guidelines. • Sequences the assigned codes using 3M software, and exercises all principles of assigning and sequencing ICD-10-CM and ICD-10-PCS codes for comprehensive coding and appropriate DRG assignment. • Participates in training programs, including educational sessions for ICD-10-CM and ICD-10-PCS coding guidelines and updates. • Follows hospital-specific guidelines to identify and facilitate prompt resolution of documentation, abstracting and/or other account problems.

• Codes and abstracts diseases, procedures from the medical record according to ICD-CM and CPT classification systems • Participates in quality improvement activities by identifying specific cases and pertinent data as requested • Completes and monitors follow up activities, complete documentation, MD Query responses, claim and DNB edits, daily • Communicates with physicians concerning incomplete documentation and clarification of diagnoses/procedures utilizing appropriate facility query process • Validates coding to assure proper APC assignment

• Accurately assigning diagnosis and procedure codes to inpatient discharges • Maintaining department specific productivity standards with a 95% accuracy rate • Querying physicians when documentation is not clear in the medical record • Collaborating with Clinical Documentation Specialists for optimal DRG assignment • Keeping abreast of coding developments through classes and seminars • Respecting patient confidentiality

• Assigns codes based on clinical documentation to office-based visits including procedures utilizing International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) • Adheres to the organization and departmental guidelines, policies and protocols • Sequences diagnoses and procedure codes as outlined in CPT, ICD and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines • Reviews all clinician documentation to support assigned codes in the health information record so that all significant diagnoses and procedures may be captured for reimbursement and data purposes • Follow up and obtain clarification of inaccurate documentation as appropriate • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines • Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement • Maintains the confidentiality of patient records • Reports any perceived non-compliant practices to the coding leader or compliance officer • Responsible for processing Coding Claim Denials and Coding Claim Rejections, when applicable