Medical Coder Evaluation & Management (E&M)

Job Description

Analyze medical records and documentation to identify services provided during patient evaluations and management Assign appropriate E&M codes based on the level of service rendered and in accordance with coding guidelines and regulations (e.g., CPT, ICD-10-CM, HCPCS) Ensure coding accuracy and compliance with coding standards, including documentation requirements for various E&M levels Stay up-to-date with relevant coding guidelines, including updates from regulatory bodies (e.g., Centers for Medicare and Medicaid Services, American Medical Association) Adhere to coding regulations, such as HIPAA (Health Insurance Portability and Accountability Act) guidelines, to ensure patient privacy and confidentiality Follow coding best practices and maintain a thorough understanding of coding conventions and principles Collaborate with healthcare professionals, including physicians, nurses, and other staff members, to obtain necessary information for coding purposes Communicate with providers to address coding-related queries and clarify documentation discrepancies Work closely with billing and revenue cycle teams to ensure accurate claims submission and facilitate timely reimbursement Conduct regular audits and quality checks on coded medical records to identify errors, inconsistencies, or opportunities for improvement Participate in coding compliance programs and initiatives to maintain accuracy and quality standards Job Requirements Certified Professional Coder (CPC) or equivalent coding certification (e.g., CCS-P, CRC) In-depth knowledge of Evaluation and Management coding guidelines and principles Proficient in using coding software and Electronic Health Record (EHR) systems Familiarity with medical terminology, anatomy, and physiology Strong attention to detail and analytical skills Excellent communication and interpersonal skills Ability to work independently and as part of a team Compliance-oriented mindset and understanding of healthcare regulations Strong organizational and time management abilities Continuous learning mindset to stay updated on coding practices and changes