The Outpatient Coder is responsible for reviewing outpatient medical records and assigning accurate diagnostic and procedural codes. This role ensures timely coding, supports revenue cycle integrity, and partners with providers to clarify documentation when needed.
Key Responsibilities
Coding & Documentation Review
Assign ICD-10-CM and CPT codes for outpatient records
Ensure coding is completed within 3 days of discharge
Maintain 98% coding accuracy and meet quality benchmarks
Abstract and maintain complete and accurate coding records
Query providers for clarification of incomplete or unclear documentation
Work closely with physicians, nursing staff, Case Management, and Business Office
Follow up on uncoded or delayed accounts
Quality & Compliance
Monitor coding quality and identify error patterns
Ensure compliance with federal and state reimbursement guidelines
Support audits and participate in process improvement initiatives
Systems & Tools
Utilize coding and abstracting systems such as 3M and Meditech
Maintain productivity and turnaround time standards
Additional Contributions
Assist with training and education for staff and providers
Participate in departmental quality improvement efforts
Qualifications
High school diploma or equivalent required
CPC or COC certification (or actively working toward certification)
Minimum 1 year of outpatient coding experience preferred
Strong knowledge of ICD-10-CM, CPT coding, and medical terminology
Understanding of anatomy and physiology
Proficiency with EMR and coding systems
Strong attention to detail, time management, and problem-solving skills
Ability to collaborate effectively with providers and healthcare teams
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