• Evaluates medical records and provides clinical and surgical abstraction for complex surgical services • Accurately codes diagnostic and procedural information • Consults with medical providers for clarifications • Abstracts clinical diagnoses and procedure codes • Ensures compliance with coding rules and regulations • Compiles daily and monthly reports

• 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