Use coding conventions and guidelines to abstract, analyze and accurately assign ICD (Internal Classification of Diseases) diagnosis codes and CPT (Current Procedural Terminology) principal and secondary procedural codes to ambulatory, clinic, provider and outpatient services.

Use coding conventions and guidelines to abstract, analyze and accurately assign ICD (Internal Classification of Diseases) and CPT (Current Procedural Terminology) principal and secondary and procedural codes to inpatient, ambulatory and outpatient medical records.

The Clinical Documentation Improvement Specialist (CDIS) is responsible for competency in coordinating and performing day to day operations, providing concurrent and/or retrospective review, and improving documentation of all conditions, treatments, and care plans to ensure highest quality of care is provided to the patient.

Oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the healthcare organization’s information privacy practices.

The Health Information Management Inpatient Coding Auditor identifies areas of under or over coding to avoid fraudulent coding and billing. Accurate coding is key to reimbursement and organizational compliance.