• Conducts CPT and ICD-10 coding reviews by detailed examination of each line item in the physician medical record • Performs chart audits to ensure correct coding and charge capture • Works closely with key revenue cycle stakeholders to understand reasons for denials, root cause analysis, and feedback to providers • Reviews patient medical records and abstracts medical data that identifies all diagnoses and procedures • Codes diagnoses, procedures, and appropriate modifiers from the medical record documentation using ICD-10-CM, CPT4/HCPCS classification systems • Refers to a computerized encoding system, written coding aids and other reference materials to ensure accurate coding for billing • Sequences diagnoses, procedures and complications by following ICD-10-CM, CPT-4, and the Uniform Hospital Discharge Data Set (UHDDS) • Consults with the CDCI team to request appropriate physician or appropriate medical staff to clarify medical record information. • Maintains productivity standards set forth in Departmental Policies and procedures • Maintains knowledge of coding and professional skills • Utilizes hospital’s cultural values as the basis for decision making and to facilitate the hospital’s goals and mission • Follows established Hospital infection control and safety procedures. • Review and respond to coding questions • Ensure billed service is being accurately coded • Perform random chart audits • Provide continual coding updates • Research coding issues that arise • Codes diagnoses and procedures from the medical record using ICD-10-CM and CPT-4/HCPCS classification systems • Sequences diagnoses, procedures and complications by following ICD-10-CM, Medicare, Medicaid, and other fiscal intermediary guidelines • Reviews charts for documentation and signature • Performs other duties as needed • Must adhere to all of BMC’s RESPECT behavioral standards