Responsible for the review and coding of inpatient and/or ambulatory surgery records utilizing ICD-10-CM and ICD-10-PCS or CPT coding guidelines and conventions for the establishment of diagnoses and procedures. The coded data is utilized for reimbursement, clinical care assessment, education, research, case mix and health care statistical reporting.

1.Reviews, analyzes and codes inpatient and/or ambulatory (outpatient) surgery records utilizing all prevailing coding guidelines and conventions for the establishment of diagnoses and procedures.

2.Queries physicians for clarification of documentation if required.

3.Participates in the documentation improvement process on conjunction with Coding management and leadership.

4.Consistently meets or exceeds coding productivity standards as per department policies.

5.Ensures compliance with CMS and other regulatory compliance guidelines.

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