Medical Coder Job Descriptions, Average Salary, Interview Questions

Responsibilities

Code patient health records for purposes of retrieval, analysis, and billing.

• Identify pertinent information in patient records.
• Assign the International Classification of Diseases, Clinical Modification (ICD), Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, creating Ambulatory Patient Classification (APC) or Diagnosis-Related Group (DRG).
• Complex coding. 
• Maintain acceptable productivity/quality rates in accordance with coding policies.
• Consult physicians when coding assignments are unclear or documenting in the record is inadequate, ambiguous, or unclear. 
• Maintain knowledge of and comply with coding guidelines and reimbursement reporting requirements.
• Audit charts for physician documentation requirements and internal coding.
• Provide physician education as appropriate. 
• Abide by the American Health Information Management Association Standards of Ethical Coding 

Requirements

Licensure / Certification / Registration:

• Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained before hire or job transfer.  
• Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained before hire or job transfer. All specialties accepted.
• Coder specializing in Cardiac credentialed from the American Academy of Professional Coders (AAPC) obtained before hire or job transfer date.
• Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained before hire or job transfer date.
• Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained before hire or job transfer date.

Education

• HS diploma equivalency or 1 year of applicable job-specific experience required.

A healthcare network in (City) is looking to add a new Medical Coder for a promising opportunity with their team in (City). In this role, the Medical Coder will be responsible for supporting medical professional corporations’ procedural and diagnostic coding of medical records for billing.

Responsibilities:

• Works with professional and non-professional staff for timely record review and ensuring the accuracy of medical documentation and sequencing ensuring that codes meet required legal and insurance rules
• Works with internal and external billing staff to ensure timely and complete billing of claims and encounters
• Collaborates and corresponds with insurance companies and healthcare professionals to resolve claim denials
• Maintains medical records both electronically and hard copies and maintains productivity and chart metrics
• Collaborates with management staff for process improvement, project work, etc.
• Performs compliance audits regarding billing, procedural and diagnostic coding to ensure documentation is accurate and timely
• Submits statistical data for analysis and research by other departments
• Performs other duties, as needed

Qualifications:

• 1+ years of Medical Record Coding & Record Review experience
• Associate’s Degree
• Certified as Professional Coder (CPC or CSS-P)
• ICD-10 certified, knowledge and experience in CPT codes required
• Proficiency with Electronic Medical Records (EMR) or Electronic Health Records (EHR) required
• Medical terminology and coding both ICD-9 and ICD-10, CPT
• Experience in Internal and External Audits
• Knowledge of the Billing Cycle
• Microsoft Office Suite proficient
• Solid problem-solving and time-management skills
• Great interpersonal skills
• Excellent communication skills (written and verbal)
• Strong attention to detail
• Highly organized

Desired skills:

• Bachelor’s Degree
• Certified Risk Adjustment Coder (CRC)
• Experience working within a Managed Care Health Organization and Outpatient Medical practice

RESPONSIBILITIES
• The Radiation Oncology Coder is responsible for ensuring all services rendered are captured timely, coded accurately, and meet documentation requirements when processed through the EMR and Billing Systems.
• Demonstrates working knowledge of all facets of role, relevant regulations, and organizational and departmental policies and procedures
• Primary Key Performance Areas: Coding Documentation, Authorization Billing, Collections, Radiation Coder Audits, & Integrity Report Findings.

QUALIFICATIONS
• Education: High school diploma or GED required.
• Certifications/Licenses: ROCC , CPC or COC preferred.
• Proficient knowledge of medical terminology, ICD-10 and CPT Coding.
• Minimum of 1 year of experience with ICD10 and CPT coding in the radiation oncology field is required.
• Proficiency in the use of the required programs to accomplish efficient coding.
• This includes, but is not limited to; Aria, Centricity, ONCO EMR, Excel, Word, Outlook, and Teams

Position function

Under the direction of the Coding Manager, functions as a coder for the Health Information Management Department to collect and classify diagnostic, procedural, and patient information from physicians and medical records. This position has the option to work remotely.

Education, qualifications, and standards

• Certified Coding Specialist (CCS) with at least one year of acute care coding experience
• OR a Registered Health Information Administrator (RHIA) with at least one year of acute care coding experience
• OR a Registered Health Information Technician (RHIT) with at least one year of acute care coding experience
• OR a Certified Coding Associate (CCA) with at least two years of acute care coding experience
• OR a Certified Professional Coder/Hospital (CPCH) with at least two years of acute care coding experience
• OR a Bachelor’s Degree with at least one year of acute care coding experience
• OR an Associate Degree with at least one year of acute care coding experience
• OR a High School Diploma with at least three years of acute care coding experience
• AND must score 80% or higher on the HIM Coding Screening competency.ICD-10, CPT-4, Medical Spelling, and Med Term Prefixes

Job summary and qualifications

As a Medical Coder, you will contribute to the company’s mission and vision by reviewing medical record documentation. You will apply appropriate coding based on the diagnosis and procedure guidelines for code selections that adhere to the company’s Coding Compliance Policies and Procedures.

Responsibilities

• You will code outpatient surgery center(s) records in a timely manner, including the assignment of ICD-10-CM, E/M, Procedure Categories, and HCPCS/CPT procedure codes
• You will code an average of 80-150 charts per day
• You are responsible for resolving codes and diagnoses with conflicting or unclear information by utilizing the query tool to gather additional information
• You will ensure 3M encoder updates are timely and accurate
• You will bill cases by furnishing completed assessments of billing supplies and implants
• You will be assisting with the preparation for accrediting bodies and/or state reviews
• You are responsible for reviewing official data quality standards, coding guidelines, company policies, and procedures, and clinical resources to assure coding knowledge and skills remain current

Qualifications

• A registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) college degree preferred
• Minimum (2) years experience in outpatient coding and/or Health Information Management required
• Minimum (1) year of experience in a medical office setting highly preferred (i.e. ambulatory surgery center, hospital, doctor’s office)
• Completed coursework in Human Anatomy & Physiology, Medical Terminology, and Introduction to Coding (including ICD-10 and CPT) preferred
• Successful completion of an ICD-10-CM training or certification curriculum; or if currently pursuing such, then completion of 50% or more of the curriculum to date with an expectation of finishing within 2 months after hire
• Must provide certification from a recognized professional coding organization, transcript from an educational institution, or similar proof of successful completion (i.e., competency assessments)