Provides coding expertise to staff within the department to assist with accurate diagnosis and procedural coding. Serves as a resource for department management, coding staff, and clinical documentation specialists to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines, and regulatory requirements. Reviews records to ensure the accurate selection of the principal/primary diagnosis and procedures and any complications or preexisting conditions in accordance with official coding guidelines.

• Provides coding expertise to department management, coding staff, and clinical documentation specialists.


• Serves as a resource for department management, coding staff, and clinical documentation specialists to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines, and regulatory requirements.


• Reviews records to ensure the accurate selection of the principal/primary diagnosis and procedures and any complications or preexisting conditions in accordance with official coding guidelines. Accuracy and quality are maintained for activities.


• Coding guidelines and regulatory changes are routinely monitored, and coders are assisted in understanding and implementing these changes.


• Conducts quality reviews of coding data and conducts regular audits and coordinates ongoing monitoring of coding accuracy and documentation adequacy.


• Provides feedback and focused educational programs on the results of auditing and monitoring activities to affected staff and presents case examples at staff meetings.


• Initiates corrective action to ensure resolution of problem areas identified during auditing/monitoring activity.


• Results of quality reviews are communicated to staff and practices implemented that reduce errors in the coding and abstracting process.


• Provides coding expertise to outside departments to assist in proper billing and outcome measurements.


• Reports noncompliance issues detected through auditing and monitoring to Compliance Department and the HIM Director.