Evaluates health record documentation and charges to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the outpatient visit. Ensures that data complies with regulatory and coding guidelines. Reviews medical information, such as diseases or symptoms and diagnostic descriptions and procedures for a given visit, to accurately assign and sequence the correct ICD-10 CM, HCPCS and CPT codes. Adheres to the quality and productivity standards set by the department.

The Medical Coder-Professional reviews, analyzes and assigns current international classification of disease (ICD) diagnosis codes, current procedural terminology (CPT) codes and other charges as appropriate based on clinical documentation for various practices in the hospital ER/outpatient/observation/inpatient and clinic settings. The Medical Coder-Professional understands and applies applicable medical terminology, anatomy, physiology, surgical technology, pharmacology and disease processes.

The Outpatient Coder II reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. Follows ICD-10-CM Official Guidelines for Coding and Reporting, Coding Clinics, and interprets ICD-10-CM coding conventions. Meets established minimum coding productivity per departmental protocol and guidelines.