Outpatient Coder

Job Summary

The Outpatient Coder provides facility outpatient coding operations with a focus on compliance, accuracy, and revenue cycle efficiency. This role supports coding best practices, collaborates with clients, and helps improve coding and documentation processes.

Responsibilities

• Assign accurate ICD-10-CM, CPT, and HCPCS codes to outpatient medical records, including same-day surgery, observation, ED, clinic, and ancillary encounters.
• Ensure coding assignments meet current coding guidelines and compliance standards, including CMS, AHA, AHIMA, and NCCI requirements.
• Abstract pertinent data from clinical documentation and enter it into the client's coding system or EHR.
• Review documentation to ensure it supports diagnoses, procedures, and medical necessity.
• Work with providers and clinical staff to clarify documentation and resolve discrepancies.
• Contribute to audits and reviews that support compliance, revenue integrity, and performance improvement.
• Support consulting projects such as backlogs, coding quality assessments, and education initiatives.
• Maintain productivity and accuracy standards defined by the consulting firm and/or client contracts.
• Stay current on coding regulations and industry changes affecting outpatient coding practices.
• Perform other duties as assigned.