Coder Specialist, Office Visit E&M Rheumatology

The Coder I Specialist Professional - Office Visits E&M reviews electronic medical record documentation and applies ICD and CPT codes according to official coding guidelines, with a focus on professional and office visits.

This role abstracts key data elements necessary for billing and data analysis.

Key responsibilities

• Review and code patient records for hospitalist rounds and office visits, including repetitive or non-invasive procedures.
• Analyze medical record documentation to assign ICD diagnosis codes, CPT procedure codes, modifiers, hierarchical condition categories, complications, and comorbidities.
• Evaluate diagnosis and procedure coding against Outpatient Code Editor and National Correct Coding Initiative edits.
• Validate that clinical documentation accurately reflects the patient's condition, treatment, and diagnoses.
• Identify missing, incomplete, or inconsistent documentation and seek clarification when needed.
• Enter data elements required for abstraction.
• Meet established coding accuracy and productivity standards.
• Apply coding guidelines independently using strong analytic judgment.
• Stay current on coding and industry changes through continuing education.
• Support process improvements to improve efficiency, reduce costs, and enhance coding services.
• Follow AHIMA/AAPC Standards of Ethical Coding and official coding guidelines.