Outpatient Coder 1

HIM Outpatient Coder 1 is responsible for coding and abstracting outpatient medical records, including emergency room, clinic, recurring, and diagnostic visits. This role reviews clinical documentation in the patient health record to accurately assign and sequence ICD-9 and CPT codes for reimbursement and data collection, with transition to ICD-10-CM.

Responsibilities

• Code outpatient diagnostics, outpatient clinics, recurring visits, and emergency room visits using ICD-9 or CPT codes as appropriate.
• Maintain a yearly average accuracy rate of 94% during internal and/or external coding audits.
• Verify patient information and ensure all codes and abstracted information are applied to the correct patient encounter.
• Review records for coding purposes and identify any documents that do not belong to the patient or encounter.
• Ensure accurate use of modifiers when coding patient encounters.
• Query physicians when additional information is needed to clarify diagnoses, symptoms, or reasons for services provided.
• Ensure coded data reflects care rendered, supports patient safety, and enables accurate reimbursement.
• Evaluate documentation to confirm diagnosis and treatment are internally consistent and meet accreditation standards.
• Report unusual circumstances or possible risk factors to coding leadership.
• Participate in ICD-10 education sessions and maintain competency through continuing education.
• Follow safety, infection control, HIPAA, and organizational standards.
• Perform other related duties as assigned.