• Reviews emergency room medical records to assign ICD, CPT, HCPCS codes accurately • Meets and exceeds productivity and quality standards • Reviews physician documentation and performs audits to determine accuracy as needed • Updates charges (as needed) and processes the records in a timely manner • Reviews tasks and corrects codes as needed • Provide training to fellow staff to improve coding outcomes

• Reviews outpatient medical records to assign ICD-10-CM, CPT-4, and HCPCS codes accurately for same day surgery and observation accounts • Meets and exceeds productivity and quality standards (target is 6.25/hour – SDS, 3.5/hour – OBS) • Updates charges (as needed) and processes the records in a timely manner • Reviews tasks and corrects codes as necessary

• The Surgical Coder for Spine is responsible for accurate and compliant coding of complex orthopedic spine procedures across all care settings. • Code high-complexity spine procedures (e.g., fusions, decompressions, instrumentation, revisions). • Verify all documentation is complete and compliant. • Assign codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines. • Follow coding conventions and ensure accurate assignment of CPT (including add-on codes, modifiers, bundling rules). • Validate levels, laterality, approach (anterior/posterior). • Identify missed billable components (e.g., additional levels, hardware, biologics). • Query provider for any necessary clarification related to unclear, unspecified or missing/incomplete documentation. • Apply payer-specific coding rules and edits. • Research, analyze, recommend, and facilitate a plan of action to correct discrepancies and prevent future coding errors.

• Perform diagnosis coding of inpatient, outpatient, and physician office medical records • Record all process information in system in accordance with contract and organizational guidelines • Review feedback from Senior Coders to improve accuracy and quality of work • Maintain security and confidentiality of medical records and Protected Health Information (PHI)