Outpatient Professional Coder

Using established coding principles and procedures, reviews, analyzes, and codes diagnostic and/or procedural information from patient medical records for reimbursement and billing purposes.

Accurately abstracts information from the medical record for compilation of a patient database that supports medical research projects, patient care evaluation, and administrative decision-making related to patient care.

Supports accurate reimbursement, provider/patient continuity, database integrity, and compliance with coding guidelines, third-party reimbursement policies, regulations, and accreditation standards.

Key responsibilities

• Identify diagnostic and operative procedures for coding by thoroughly reviewing the patient’s medical record.
• Analyze provider documentation to assign or verify appropriate Evaluation & Management (E&M) CPT codes when applicable.
• Verify and request documentation to support compliance.
• Assign diagnostic and procedural codes according to established coding principles and guidelines using encoder software.
• Review charges and assign appropriate facility E&M levels when applicable.
• Use APC reimbursement expertise to assign ICD-9-CM diagnoses and ICD-9-CM/CPT procedures.
• Verify completeness of the medical record within the electronic medical record and report discrepancies to a supervisor.
• Communicate with medical staff to clarify documentation.
• Review system-generated error reports and correct missing data elements when needed.
• Review and correct coding errors, edits, rejections, and disputes.
• Follow Remote Coding Program policy when participating in the remote coding program.
• Maintain knowledge of applicable federal, state, and local laws, regulations, organizational integrity standards, and related policies.
• Perform other related duties as assigned.