• 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

• Reviews medical documentation at a proficient level from clinicians, qualified health professionals and hospitals in order to assign diagnosis and procedure codes utilizing ICD-10 CM/PCS, CPT, and HCPCS. • Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations an EMR and/or Computer Assisted Coding software. • Adheres to the organization and departmental guidelines, policies and protocols. • 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. • Conduct independent research to promote knowledge of coding guidelines, regulatory policies and trends. • 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. • Meets then exceeds departmental quality and productivity standards. • Recommend modifications to current policies and procedures as needed to coincide with government regulations. • Responsible for processing Coding Claim Denials and Coding Claim Rejections, when applicable