This role plays a vital part in maintaining the integrity of the revenue cycle by verifying documentation accuracy and reducing denial occurrences through auditing and accurate coding. The position requires strong analytical skills, a deep understanding of medical terminology and coding standards, and a commitment to ensuring billing accuracy and compliance with regulatory guidelines.

Responsibilities include:

Reviewing and assigning appropriate CPT, ICD-10-CM, and HCPCS codes based on physician charges
Accessing hospital portals to verify that billing codes accurately reflect documented patient services and procedures
Ensuring patient record documentation meets coding and compliance requirements
Collaborating with the Denials Department to identify recurring patterns of omissions, errors, or documentation discrepancies
Communicating findings to administration to support corrective actions and reduce future issues
Coding hospital consults, follow-ups, diagnostic testing, and clinic diagnostic testing
Conducting daily reviews to detect and correct billing errors or omissions
Auditing charts for completeness and accuracy in partnership with the Medical Records Department
Verifying required details such as diagnoses, indications, and physician signatures
Identifying cloned notes or other documentation irregularities to maintain compliance and documentation standards

Medical Coder