Under general supervision, but according to established procedures, codes and abstracts patients records in order to meet billing and data collection needs of the hospital. Determines/assigns ICD-9-CM code numbers to each diagnosis and procedure documented in the patients inpatient/outpatient medical record. Abstracts information from the medial records into the HDM abstract, according to established guidelines. Sequences diagnostic and procedural codes according to hospital specified procedures and assigns MSDRG/APC as appropriate. Codes inpatient and/or outpatient medical records using ICD-9-CM and CPT-4 coding rules and guidelines. Compares charges on accounts with the procedures coded and identifies any discrepancies. If any are noted, contacts department manager to validate change and coordinates with Chargemaster Coordinator to rectify the account. Reviews and identifies any Local Coverage Determination (LCD) issues with outpatient accounts and rectifies these issues. Reports outstanding issues and potential solutions to these coding challenges to the Coding Manager. Appropriately assesses and addresses all edits (OCE, NCCI, 3M). Assesses appropriateness of APC, APG and ASC assignment. Reviews all accounts returned for medical necessity diagnoses issues and multiple procedures to validate the clinical significance for modifier application. Identifies records that are problem diagnoses and forwards to the Department Manager. Works closely with Case Coordinators in the assignment of an appropriate MSDRG for inpatient accounts. Reviews MSDRG data information and identifies working MSDRG with additional needed elements to be acquired from attending/consulting physicians for inpatient accounts. Completes daily productivity logs and submits them to the Manager. Monitors medical appropriateness of care provided to patients and reports disputable findings to the Utilization Review Department for inpatient/same day surgery/observation accounts. Collects requested data for the Department of Quality Improvement and reports findings. Provides codes to Admitting, Patient Accounting, Outpatient Clinics and various hospital departments upon request. Assists in the inpatient/outpatient coding training of employees and medical record students. Maintains at least ten continuing education hours annually.

1. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Coding Associate (CCA), Certified Coding Specialist (CCS) or other coding certification related to the specialty area. 2. Two to three years inpatient and/or outpatient coding experience. 3. Must be able to demonstrate proficiency in inpatient and/or outpatient coding.

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