Medical Coder

Position Title:

Medical Coder

Department:

Coding

Reports To:

Director of Billing

FLSA:

Non-Exempt

Position Summary:

The Medical Coder plays a crucial role in ensuring accurate coding of medical records for intraoperative neuromonitoring services. This position involves reviewing medical records and assigning appropriate codes using ICD-10, CPT, and HCPCS Level II systems. The Medical Coder ensures compliance with industry standards, regulations, and maintains accuracy in coding to support efficient billing processes. The ideal candidate will have a strong attention to detail, solid analytical skills, and the ability to work both independently and collaboratively within a team.

Essential Duties \& Responsibilities:

• Review medical records and assign codes for diagnoses and procedures using ICD-10, CPT, and HCPCS Level II coding systems. Ensure coding accuracy and compliance with regulatory standards.
• Examine chart elements, including face sheets, operative reports, History and Physical (H\&P), and Professional and Technical Reports.
• Verify the accuracy and completeness of medical records and automation summaries.
• Prepare and submit coded information for insurance claims and work with billing staff to resolve any coding issues that may delay claims processing.
• Serve as a resource for claim edits, Local Coverage Determinations, insurance requirements, and intraoperative neurophysiological monitoring specifics.
• Follow CPT/ICD-10 coding guidelines and legal requirements to ensure compliance with HIPAA and other regulations.
• Process encounters and ensure all billable services are submitted in a timely manner.
• Stay current with coding and regulatory requirements and meet continuing education requirements for certification.
• Identify and communicate trends and educational opportunities to ensure documentation, coding, and billing accuracy.
• Identify charge-related edits to reduce denials and improve practice management system functionality.