• Code Cardiothoracic Surgery physician charges • Communicate coding rationale to physicians • Code inpatient and outpatient Cardiothoracic charges

• The Observation Coder is responsible for accurately assigning diagnosis and procedure codes to observation discharges at all McLeod Health facilities. • Possess outpatient coding knowledge and experience necessary to accurately assign ICD-10-CM codes for principal diagnosis and any applicable secondary diagnoses on all Observation encounters. • Possess outpatient coding knowledge and experience necessary to accurately assign CPT procedure codes for principal procedure and any applicable secondary procedures on all Observation encounters to arrive at the most appropriate APC assignment. • Understands and appropriately assigns all applicable modifiers to CPT procedure codes and ancillary charges required to prevent billing edits. • Queries physicians appropriately when documentation is not clear in the medical record. • Maintains department specific productivity standards with a 95% accuracy rate.

• Prioritizes and codes and abstracts high dollar charts, day after discharge, as well as interim charts • Reviews complex medical documentation at a highly skilled and proficient level from clinicians, qualified health professionals and hospitals to assign diagnosis and procedure codes utilizing ICD CM/PCS, CPT, and HCPCS • Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations utilizing an EMR and/or Computer Assisted Coding software • Assigns codes for present on admission, research, Hospital acquired Conditions and Core Measure Indicators for all diagnoses both concurrently and post-discharge • Collaborates with other departments to clarify pre-bill coding documentation issues such for inpatient and outpatient to insure reimbursement and clinical outcomes • Works claim edits for all patient types and may codes consecutive/combined accounts to comply with the 72-hour rule and other account combine scenarios • Completes informal peer-review on inpatient and outpatient coders • Tracks and trends quality information from internal and external sources to partner with the educational team on opportunities • Communicates with Medical Staff, CDI, Post -bill for documentation clarification • Utilizes EMR communication tools to track missing documentation on inpatient queries that require follow-up to facilitate coding in a timely fashion • Partners with HIM, Patient Accounts, and Integrity, when needed, to help resolve issues affecting reimbursement and outcomes • Maintains current knowledge of changes in Inpatient coding and reimbursement guidelines and regulations as well as new applications or settings for coding all types of patients • Must be able to use critical decision-making skills to determine when to query to clarify documentation independently for outcomes, reimbursement and benchmarking

• Monitor coding operations with respect to workflows and regular reporting: evaluate workflows for maximum efficiencies and problem solve work queue issues when accounts/charges are not flowing properly, making recommendations as necessary. • Answer charging, coding, Epic or other software related questions from coders, CDI, clinical and Revenue Cycle staff. • Perform research, run various reporting and assist with general coding as needed and as requested. • Provide coding training within the Coding Department and perform research on coding issues.