Position Summary

The Professional Fee Coder abstracts and applies codes for Outpatient Clinic settings assigning ICD-10-CM Diagnosis, E&M, CPT procedural codes, appropriate modifiers in addition to applying charges for professional services.

Position Accountabilities

Maintains established departmental policies, procedures, objectives, quality assurance program, safety, environmental and infection control standards.

Responsible for reading and interpreting various components of the medical record, such as pathology reports, radiology x-rays and scans reports, physical findings, and all treatment modalities, and uses the information to correctly abstract and assign E&M, CPT and ICD10 diagnosis codes.

Thoroughly review the physician documentation and other pertinent documentation to accurately reflect and support diagnose and procedures.

When services and diagnoses are not documented appropriately, query the physician for clarification according to facility procedures.

Adherence to current Official Outpatient Coding Guidelines, Coding Clinic, CMS, CPT Assistant and other regulatory Compliance Guidelines and Mandates.

Responsible for communicating abstracted findings, including potential risks and ideas for improvement in a timely manner to the Director.

Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops

Attends meetings as required.

Performs other related duties as assigned or requested.

Minimum Education - High School or GED

Minimum Experience - 3 or more years of pro fee physician office and ambulatory Surgical coding experience – must

pass coding test

Required Course(s) / Training - Anatomy and Physiology, Medical Terminology, and Ongoing Coding and Auditing

Educational Classes

Preferred Education - Associates of Applied Science, Registered Health Information Technology

Preferred Experience - Healthcare outpatient clinic, ambulatory surgery center

Preferred Course(s) / Training - ICD-10-CM, CPT AND HCPCS Level II

Preferred Certifications/Registration - Certifications as CCS, RHIT, RHIA through AHIMA and/or CPC COC or Outpatient

Specialty Coder Certification through AAPC