Medical Billing and Coding

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – Cardiology

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings, ensuring expert application of modifiers and E/M guidelines
• Perform entry-level facility coding for simple outpatient encounters (e.g., diagnostic imaging, labs) and basic inpatient services (e.g., uncomplicated admissions, short stays) using ICD-10-CM and ICD-10-PCS, where applicable
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – ENT, Audiology

• Responsible for assisting the coding department with the day-to-day non-coding duties support activities
• Assigns codes to office-based visits and procedures using the International Classification of Diseases (ICD-10-CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
• Resolve coding edits to assure accurate and complete claims submission
• Sequences diagnoses and procedure codes as outlined in CPT, ICD-10-CM, and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines
• Reviews all clinician documentation to support assigned codes in the health information record
• Follows up and obtains clarification of inaccurate documentation as appropriate
• Codes risk adjustable encounters, resolves CRMs, and trends coding denials, as assigned
• Conducts formal coding and documentation reviews, clinician reviews and quality reviews, as assigned
• Assists with coding research functions and education activities
• Creates clinician coding and documentation education based on query trends or ad-hoc requests
• Adheres to the organization and departmental guidelines, policies, and protocols.
• Abides by Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement
• Maintains confidentiality of patient.

Physician Support Coder

• Evaluate medical records and provide clinical and surgical abstraction
• Accurately code diagnostic and procedural information
• Consult with medical providers for record clarification
• Ensure compliance with coding rules and regulations
• Compile reports and tabulate data from medical records
• Identify validation edits and ensure accurate coding
• Work independently under regular supervision

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Coder II – Cardiology

Coder II – ENT, Audiology

Physician Support Coder

Complex Coder, Surgical Cardiology