Medical Coder - Outpatient

Job Summary

Requires advanced knowledge of ICD and CPT code sets and applicable Medicare/Medicaid rules and guidelines. Reviews and interprets patient medical record documentation to identify diagnoses and procedures and assigns ICD-10-CM and CPT-4 codes accurately and timely to the highest level of specificity for ambulatory surgery, special procedure, observation, emergency department, outpatient ancillary, and clinic visit records.

Primarily codes complex ambulatory surgery and observation visit medical records. Identifies and abstracts specified information from patient records and enters data into the electronic health record system for billing and reporting. Assists with outpatient ancillary, clinic, specialty clinic, and emergency room record coding as needed. Maintains a minimum expected accuracy rate of 95%.

Communicates with physicians and other providers regarding documentation requirements and collaborates with Clinical Documentation Specialists to improve documentation and coding accuracy.

Job Responsibilities

• Review health record documentation and assign ICD-10-CM and CPT-4 codes to the highest level of specificity.
• Apply coding rules and policy guidelines for ambulatory surgery, special procedure, and observation cases.
• Abstract required medical record data into the electronic health record system.
• Submit physician queries post-discharge to request clarification or additional documentation.
• Identify and report documentation and risk management issues.
• Maintain current knowledge of coding and documentation changes, rules, and guidelines.