• Interprets clinical and diagnostic documentation for outpatient care • Assigns appropriate ICD-CM and CPT codes • Verifies documentation substantiating codes assigned • Assists in resolving incomplete/missing chart documentation • Participates in continuous coding audit and performance management program • Maintains coding accuracy rate of not less than 95% • Attends required training classes annually • Communicates with management about backlog situations and necessary documents • Alerts management to coding irregularities and trends

• Reviews medical record documentation to determine appropriate billing codes and necessary documentation • Reviews surgical documentation in the record to identify all pertinent facts necessary to select the comprehensive diagnoses and procedures • Codes evaluation and management services and procedures for pain management to appropriate CPT code and ICD-10 code • Contacts with physicians to review documentation, resolve coding and secure signature of all unsigned dates of service • Assists with efforts to increase physician awareness of documentation requirements • Performs other duties as assigned

• Reviewing documentation and selecting the appropriate procedure and/or diagnosis code to be entered in billing documents • Ensuring that teaching physician requirements are met and are clearly reflected in the documentation • Other duties as assigned

• Providing coding and abstracting services for clients on facility same day surgery / observation and interventional radiology CPT records • Reviewing medical records to identify pertinent diagnoses and procedures • Ensuring appropriate DRG assignment • Maintaining communication and contributing to a positive company image