General Summary

Under direct supervision accurately codes hospital Ambulatory Surgery and Observation visit records for the purpose of appropriate reimbursement, research and compliance with federal and state regulations according to established ICD-10 diagnostic coding and CPT-4 procedure coding classification systems.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed. Identifies and assigns ICD-10 diagnostic codes and CPT-4 procedure codes to outpatient, ambulatory surgery, and observation visits for the purpose of reimbursement, research and compliance with federal and state regulations.
2. Monitors assigned work on a daily basis in order to facilitate the billing process within the established timeframes. Codes and abstracts records within timeframes established for each patient type.
   1. Maintains coding quality accuracy rate of 90%.
   2. Maintains productivity rate of 95%.
3. Communicates with various departments within the hospitals regarding billing and registration issues. Refers any problems to management timely, providing clear details.
4. Complies with AHIMA standards of ethical coding and coding compliance guidelines.
5. Demonstrates support and compliance with University of Maryland Medical System mission, vision, values statement, goals and objectives and policies. Performs other duties or projects such as coding corrections as assigned by the manager.