Overview Reviews, analyzes, and codes medical record documentation to include, but not limited to, medical, diagnostic, and procedural information for the correct ICD-10, CPT and/or HCPCS codes to the greatest specificity. Abstracts demographic and coding information into the information system accurately and completely. Reviews documentation for medical necessity. Audits orders and claims before submission for accuracy and to minimize claim denials. Assesses records and prepares reports. Provides technical guidance to physicians and other departmental staff in identifying and resolving issues or errors. Develops effective working relationships with physicians and other stakeholders. Primary coding responsibility is all Evaluation and Management (E/M) leveling along with additional ancillary services done in an office setting. Responsibilities Reviews, analyzes, and codes medical record documentation to include, but not limited to, medical, diagnostic, and procedural information for the correct ICD-10, CPT and/or HCPCS codes to the greatest specificity. Abstracts demographic and coding information into the information system accurately and completely. Reviews documentation for medical necessity. Audits orders and claims before submission for accuracy and to minimize claim denials. Assesses records and prepares reports. Provides technical guidance to physicians and other departmental staff in identifying and resolving issues or errors. Develops effective working relationships with physicians and other stakeholders. Primary coding responsibility is all Evaluation and Management (E/M) leveling along with additional ancillary services done in an office setting.
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Career Level
Entry Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees