Assign based on documentation contained in the medical records. Only accurate and properly documented services can be billed. If there is inadequate information (i.e. missing operative report, missing pathology report, pertinent ancillary reports, etc.) on which to base code assignment, the responsible party must be contacted and coding must be deferred until the required information is available.Adheres to applicable federal state, local, and private requirements, policies and procedures.Ability to code all outpatient records (SDS, OBS, Ancillary, Anesthesia, Cardiology, Assistant Surgeon, OB-Gyne, Denials Management ) with an accuracy rate of 95% or greater. Meets and maintains established productivity standards. Assures the accuracy, integrity, and consistency of coded data.Strict adherence to AHA Coding Clinic and Official Guidelines for Coding and Reporting. CMS approved guidelines for ICD-9-CM coding.Strict adherence to AHIMA’s Standards of Ethical Coding. Remain current and knowledgeable regarding code and APC assignment.Have been working through Same Day Surgery, Observation, and Ancillary accounts using Epic system environment.Have been working through Anesthesia, Cardiology, Assistant Surgeon, OB-Gyne, Denials Management accounts using Meditech and E-Clinical Works system environment.

The Medical Coder / Auditor /Abstractor undergoes extensive medical coding, auditing and/or abstracting education in preparation to providing coding, abstracting and auditing services on inpatient, outpatient, physician, or emergency room medical records using the latest appropriate International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding systems.

Assesing patients: infants, children, adult and pregnant mothers, taking vital signs, making and updating medical/maternal/family planning records, vaccinating infants thru EPI, wound cleaning and dressing, assisting in maternal delivery and newborn care, implementing family planning (Contaceptive Pills, DMPA, IUD, Tubal Ligation, Vasectomy), implementing TB-DOTS program, had joined Ligtas Tigdas ang Pinas Program as Vaccinator, had joined Operation Tuli Programs.checking supplies and equipments on E-Cart-inserting and maintaining Intravenous line-doing admission charting -securing consent for admission to the patients/relatives of the patients-preparing and giving medications-assisting in suturing and wound cleaning and dressing-taking vital signs and chief complaints of patients in OPD-performing direct Intravenous Push-inserting Foley catheter-doing cardiac compressions-assisting in NSD and newborn care-making referrals and carrying out doctor’s orders