Medical Coder

Medical Coder [$20 - $32/hour] Scope of Work

• Annotate and review outpatient medical records (physician office, clinic, ambulatory surgery, and hospital outpatient encounters), ensuring accurate assignment of ICD-10-CM and CPT/HCPCS codes based on documentation
• Apply Evaluation & Management (E&M) leveling to outpatient visits using official guidelines (medical decision making or total time) to validate and enrich datasets
• Apply outpatient-specific coding conventions, including diagnosis coding guidelines for outpatient services, modifier usage, medical necessity, and linking diagnoses to procedures
• Collaborate with project stakeholders via written and verbal communication to clarify requirements and resolve ambiguities in clinical documentation
• Provide high-quality feedback on coding guidelines and edge cases to improve project workflows and model understanding

Preferred Qualifications

• Active AAPC Certified Professional Coder (CPC) certification is required.
• Comprehensive understanding of ICD-10-CM and CPT coding systems and outpatient E&M leveling guidelines
• Hands-on experience coding in outpatient settings (e.g., primary care, specialty clinics, ambulatory surgery centers, outpatient hospital departments)
• Experience with diverse clinical documentation types and associated coding challenges, such as office visit notes, procedure notes, and operative reports
• Proficiency with both written and verbal communication, with a strong attention to clarity and detail
• Access to up-to-date official ICD-10-CM, CPT, and HCPCS Level II coding books, as well as E&M guidelines