Medical Coder Evaluation & Management (E&M)

Medical Coder

Key Responsibilities:

• Analyze medical records and documentation

  to accurately identify services provided during patient evaluations and management encounters.

• Assign appropriate E&M codes

  based on the level of service, adhering to coding guidelines and regulations such as

  CPT, ICD-10-CM, and HCPCS

  .
• Ensure coding accuracy and compliance with all coding standards, including

  documentation requirements

  for various E&M levels.
• Stay current with all relevant coding guidelines and updates from regulatory bodies, including the

  Centers for Medicare and Medicaid Services (CMS)

  and the

  American Medical Association (AMA)

  .
• Adhere to coding regulations such as

  HIPAA

  to ensure patient privacy and confidentiality.
• Collaborate with healthcare professionals, including physicians and nurses, to obtain necessary information and

  address coding-related queries

  .
• Work closely with billing and revenue cycle teams to ensure

  accurate claims submission

  and timely reimbursement.
• Conduct regular

  audits and quality checks

  on coded medical records to identify errors or opportunities for improvement.
• Participate in coding compliance programs and initiatives to maintain high accuracy and quality standards.

Job Requirements:

• A

  Certified Professional Coder (CPC)

  or an equivalent coding certification (

  CCS-P, CRC

  ) is mandatory.

• In-depth knowledge of Evaluation & Management coding guidelines and principles

  is required.
• Proficiency in using

  coding software

  and

  Electronic Health Record (EHR) systems

  .
• Strong familiarity with medical terminology, anatomy, and physiology.
• Exceptional

  attention to detail and analytical skills

  .
• Excellent communication and interpersonal skills to effectively collaborate with providers and staff.
• A strong compliance-oriented mindset and understanding of healthcare regulations.
• The ability to work both independently and as part of a team.
• Strong organizational and time management abilities, with a continuous learning mindset.