Medical Coder

Essential Duties & Responsibilities

• Review medical records and assign codes for diagnoses and procedures using ICD-10, CPT, and HCPCS Level II coding systems.
• Ensure coding accuracy and compliance with regulatory standards.
• Examine chart elements, including face sheets, operative reports, History and Physical (H&P), and Professional and Technical Reports.
• Verify the accuracy and completeness of medical records and automation summaries.
• Prepare and submit coded information for insurance claims and work with billing staff to resolve any coding issues that may delay claims processing.
• Serve as a resource for claim edits, Local Coverage Determinations, insurance requirements, and intraoperative neurophysiological monitoring specifics.
• Follow CPT/ICD-10 coding guidelines and legal requirements to ensure compliance with HIPAA and other regulations.
• Process encounters and ensure all billable services are submitted in a timely manner.
• Stay current with coding and regulatory requirements and meet continuing education requirements for certification.
• Identify and communicate trends and educational opportunities to ensure documentation, coding, and billing accuracy.
• Identify charge-related edits to reduce denials and improve practice management system functionality.