I. General Summary

• Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems.

II. 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.
a. Analyzes, codes and abstracts complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment.
b. Utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed.
c. Collaborates with other senior coders (and the other coding staff) with sharing coding information and providing coding advice to colleagues regarding complex cases to be coded.

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.
a. Maintains coding quality accuracy rate of 90%.
b. 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. Compose appropriate coding queries, work collaboratively with CDI, understand Potentially Preventable Complications (PPC's)/Maryland Hospital Acquired Conditions (MHAC's), and Prevention Quality Indicators (PQI's) and their impact.

4. Communicates with the Auditing team to discuss audit findings and working collaboratively in making sure that all accounts are coded appropriately and meet standards of compliance

5. Complies with AHIMA standards of ethical coding and coding compliance guidelines.

6. 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.