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Job Summary:

Responsible for abstracting clinical information and assigning CPT-4 and ICD-10 codes from medical records and documents to support physicians professional fees, including but not limited to outpatient evaluation and management (E/M) services and procedures in accordance guidelines.

Position Responsibilities:

• Abstract billing for outpatient evaluation and management codes, minor surgical procedure(s) and HCPCS (supplies and pharmaceuticals) codes from provider documentation to include; assignment of CPT-4, ICD-10-CM codes and modifiers.

• Research simple coding/billing issues for the physicians to identify and recommend the most appropriate method of coding/billing. Research may involve interaction with such organizations as American Medical Association, specialty societies, or other coding consultants.

• Analysis of the medical record to determine the appropriateness of coding and potential patterns of abuse. Including working with the Coding/Charge/Audit Analyst(s) to resolve the issue(s).

Position Qualifications Required / Experience Required:

• Minimum of 5+ years in evaluation and management coding
• Ability to perform functions in a Microsoft Windows environment.
• Ability to be detailed oriented and perform tasks at a high level of accuracy.
• Ability to make sound decisions.
• Demonstrate good communication and team work skills.
• Previous experience with an electronic legal health record system preferred.
• Knowledge of Anatomy & Physiology/ Medical terminology required.

Required Education:

• High School Diploma or GED required.
• Knowledge of Anatomy & Physiology/ Medical terminology required
• CPC (Certified Professional Coder) Certified required or must obtain within six months of hire.