GENERAL STATEMENT OF DUTIES:  The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing; To be accountable of conversion of diagnoses and treatment procedures into codes using an international classification of diseases; Must be skilled in the sequencing of diagnoses/procedures to optimize reimbursement; Ensures that records are coded in an accurate and timely manner. ESSENTIAL FUNCTIONS:

• Abstracts pertinent information from patient records. Assigns ICD-9-CM and CPT/HCPCS codes;
• Codes all diagnoses/procedures in accordance to ICD-9-CM coding principles and Coding Manual;
• Ensures that records are coded within 24 hours of discharge; Reviews charts thoroughly to ascertain all diagnoses/procedures;
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes;
• If diagnoses not available on chart, contacts responsible physician in a professional, tactful manner;
• If there is a question regarding the diagnoses/code, bring to Director’s attention; Utilizes and is familiar with computerized coding/abstracting software (3M); 
• Meets productivity standard of assigning codes to a minimum of five charts per hour on federally funded patients and seven charts on non-federally funded patients;
• Keeps abreast of coding guidelines and reimbursement reporting requirements;
• Brings identified concerns to supervisor or department chief for resolution;
• Works with CDM manager on updating codes in CDM;
• Updates and maintains the Coding policy and Procedures Manual on an ongoing basis;
• Notifies Director whenever working more than 48 hours behind work deadlines;
• Meets quality standards of having 95% of principal diagnosis and procedure correctly coded;
• Assists with state requirements and reports;
• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems;
• Acts as a liaison to hospital staff on coding and coding related issues, assists in providing education to medical staff and other clinicians on coding guidelines as relates to clinical documentation;
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guideline;
• Maintains acceptable working relationship within the department, and with other departments within the facility;
• Performs other duties as assigned.