Medical Records Coder - Associate

Under direct supervision, responsible for reviewing inpatient and outpatient coding, ensuring coding compliance with federal regulations, and maintaining up-to-date coding guidelines and policy changes.

This role supports medical billing by abstracting complex patient information from medical records and coding diagnoses and procedures using ICD-10 and CPT classification systems.

Responsibilities

• Review, interpret, and assign diagnostic and procedural codes based on medical record documentation according to correct coding principles.
• Provide technical work in documentation and coding for medical billing.
• Abstract patient-related data from medical records and code diagnoses and procedures using ICD-10 and CPT codes.
• Perform coding-related charge review and claim edits daily to support timely and accurate billing.
• Obtain medical records and charge fee information from patient care areas.
• Contact other facilities to obtain medical records and information needed to bill for services rendered.
• Verify charge capture and physician notes for completeness.
• Ensure required signatures are present and documentation guidelines are followed.
• Review charge documents for completeness.
• Perform other duties as assigned.