ORGANIZATIONAL GOALS OR OBJECTIVES: The organizational goals and objectives of this position are to: Accurate, complete, compliant, and timely coding of medical services to provide actionable data for decision support in pursuit of mission objectives. Active support in reducing costs and lost revenue through mitigation of service wastes by advocating for quality provider documentation, value added coding and documentation education for providers and staff, and standardized workflow processes where possible. DUTIES 1. Codes inpatient encounters at a Military Medical Center (with numerous medical specialties). Reviews clinical documentation and assigns appropriate diagnostic and procedural codes for inpatient, inpatient professional rounds, External Resources Sharing Agreement (ERSA), and any other inpatient medical encounter utilizing established DoD and industry coding guidelines. Codes medical records using the appropriate International Classification of Diseases (ICD- latest version) diagnosis and/or procedural codes, American Medical Association Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS), Current Dental Terminology (CDT) codes, Diagnostic Related Groups (DRG's), or other code taxonomies used to describe the provision of medical services for one or more medical conditions. Codes complicated medical records (such as critical ill patients requiring extended stays or novel diagnostic and treatment methods or having diagnostic, surgical, and therapeutic procedures on specific DRG's that are identified as difficult to classify). Reviews a variety of electronic and paper documentation for completeness and compliance, uses a logical thought process and experience to determine proper provider documentation, lab tests, graphic records, pharmaceutical or medication profiles, pathology reports, radiology reports, etc. Using a practical knowledge of medical terminology, anatomy, physiology, and medical and surgical procedures interprets and extracts data from component parts of clinical records to assign appropriate codes, such as operations and special therapeutic procedures. Codes inpatient discharge records with correct and optimal DRG assignment, Relative Weighted Product (RWP) and Relative Value Units (RVUs) in order for the Center to receive correct reimbursement or workload credit. Coding may also include ambulatory surgery and/or Emergency Department encounters for the Centers. Adheres to AFMS and DoD timelines requirements for coding of records. Uses military medical software programs to retrieve documentation (such as AHLTA, AVHE, Essentris, HAIMS) and (CCE Encoder, CHCS) to assign codes. When needed may use military medical systems to remotely code inpatient, ambulatory surgical, or professional services encounters in providing contingency assistance to other Medical Centers. 2. Identifies inconsistencies or discrepancies among medical documentation involved in coding encounters. Reviews encounter and/or record documentation to identify inconsistencies or discrepancies that may cause inaccurate coding, medico-legal re-percussions or impacts quality patient care. Identifies any problems with legibility, abbreviations, etc., and brings to the providers attention. Examines records for proper sequence of documents, presence of authorized signatures, and sufficient data is documented that supports diagnosis, treatment administered, and results obtained. Develops and submits a written (electronic or hard copy) query IAW AFMS guidelines to the provider to request clarification of provider documentation that is conflicting, ambiguous, or incomplete in regards to any significant reportable condition or procedure. Works with providers to resolve documentation issues to support coding compliance. Assigns accurate codes to encounters based upon provider responses to queries and reports queries and responses IAW AFMS guidance. 3. Provides coding and documentation advisory services to medical staff on an individual or group basis. Acts as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Based on contacts from the medical staff identifies training opportunities and works with coding training personnel to focus on consistency and clarity of coding advice provided. May assist medical training specialist with providing initial coding training to providers by providing guidance to professional and technical staff in documentation requirements for coding. 4. Provides coding and documentation advisory services to medical staff on an individual or group basis. Acts as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Based on contacts from the medical staff identifies training opportunities and works with coding training personnel to focus on consistency and clarity of coding advice provided. May assist medical training specialist with providing initial coding training to providers by providing guidance to professional and technical staff in documentation requirements for coding.