• The responsibility of the Coding Specialist Certified is to search a patient's entire medical record to ensure comprehensive coding and abstracting utilizing the coding rules, principles and ethics under the supervision of the Coding Supervisor and Manager, Health Information Management. • With quality and reimbursement contingent upon coding, it is the responsibility of the Medical Center Coding Specialist Certified to have knowledge of DRG methodology, ICD-10, CPT-4 and APC coding rules and principles. • Reviews the medical record for diagnoses and procedures performed. • Analyzes and searches the documentation listed in the entire medical record for all documented clinical information (diagnoses and procedures) in accordance with established procedures, daily, and trained in a minimum of 3 out of the 4 following areas: Inpatient records, Outpatient records, Emergency Room records, Clinical /Diagnostic records. • Identifies and sequences principal diagnosis, secondary diagnoses, principal procedures, complications and comorbid conditions, for optimal reimbursement, utilizing proper coding practices, on a daily basis. • Selects ICD 10-, CPT-4, DRG code assignments. • Assigns proper ICD-10, CPT-4, DRG codes for all diagnoses, procedures, complications, and comorbid conditions during the course of hospitalization after researching the entire record, maintaining a 95% accuracy rate, on a daily basis. • Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.

• Assign ICD-10, CPT, HCPCS and modifiers codes from documentation • Review and appropriately resolve pre-bill edits • Review and appropriately resolve coding denials • Meet or exceed productivity standards • Meet or exceed accuracy rate of 95.5% in monthly internal audits • Effectively present coding issues to internal team members, internal clients or external clients • Deliver information in a one-on-one or small group format to peers • Meet deadlines and complete assignments before monthly closing dates • Locate and apply CCI, LCD, NCD and other applicable coding rules and client specific guidelines • Other duties as assigned

• Reviewing documentation in inpatient and/or IVR (interventional radiology) medical records • Accurately and completely assigning appropriate ICD-10-CM diagnostic and ICD-10-PCS/CPT-4 HCPCS procedural codes • Abstract demographic and coding information accurately and completely • Codes and abstracts medical records with a minimum of accuracy • Meets productivity standards • Queries providers, if needed to further clarify code • Manages additional coding responsibilities • Resolves coding edits and reminders, correcting abstracting and coding issues in a timely manner • Completes and routes problem accounts, ready to code, high dollar and other accounts daily

• Reviews and/or assigns CPT and/or diagnosis codes (ICD-10-CM, including HCC risk adjustment) for primary care and/or specialty clinic services (E&M, office procedures, inpatient hospital rounding, OB services, outpatient general practice procedures, etc.) with a high degree of accuracy. • Performs documentation reviews with the use of department auditing tools, shares results with providers and auditing team, and identifies educational opportunities. • Collaborates with providers, clinical team members, and/or other departments when completion or clarity is needed within the medical record to accurately complete coding functions. • Manages and maintains coding inventory responsibilities related to payer denials and claim edits to ensure timely reimbursement for services provided. • Researches payer policies. • Manages and maintains operational coding functions to ensure charge capture of all billable services. • Performs world class service to our customers, responding timely and professionally to inquiries.