Medical Coder

Job Description:

Key Responsibilities

• Review and audit clinical documentation and medical notes for accuracy and completeness.
• Assign appropriate CPT, ICD-10-CM, and HCPCS codes based on provider documentation.
• Ensure accurate coding in accordance with official coding guidelines and payer requirements.
• Identify coding errors, discrepancies, and missing documentation.
• Verify that medical notes support the assigned codes and billed services.
• Perform regular audits to ensure coding accuracy and compliance.
• Review evaluation and management (E/M) codes and ensure appropriate level selection.
• Communicate coding discrepancies and provide feedback to relevant teams.
• Maintain confidentiality of patient information in compliance with HIPAA regulations.
• Stay updated on CPT code changes, coding guidelines, and industry updates.