Outpatient Coder II

Under the general supervision of the Outpatient (OP) Coding Manager and OP Coding Supervisor, the OP Coder reviews outpatient records and ensures accurate, timely, and compliant assignment of ICD-10-CM, CPT, HCPCS, and modifiers to support correct APC assignment.

The role works closely with coding leadership and OP Coding Validators to maintain coding uniformity, consistency, and accuracy in alignment with ICD-10-CM, CPT, official coding guidelines, federal and state regulations, and American Hospital Association guidance.

Key responsibilities

• Review complete electronic and scanned medical records of discharged patients and assign ICD-10-CM, CPT/HCPCS, and modifiers from the documentation.
• Abstract coded data and patient information into the BILH coding abstracting system.
• Apply official coding guidelines, AHA Coding Clinic advice, and facility-specific standards for outpatient records.
• Sequence codes using 3M software and support appropriate APC assignment.
• Participate in training on ICD-10-CM and CPT/HCPCS coding updates.
• Identify and help resolve documentation, abstracting, and account issues.
• Review and code professional services, including surgeries and diagnostic services, as needed.
• Review rejected claims and patient inquiries related to professional services and recommend appropriate coding actions.
• Communicate with physicians, providers, managers, and other departments regarding coding questions and education.
• Participate in provider orientation, documentation reviews, and ongoing education efforts.
• Support revenue cycle teams and provide feedback to improve coding quality and compliance.