Medical Coder - E&M

E&M Medical Coder Inpatient & Outpatient

Location: Chennai, Tamil Nadu
Department: Medical Coding US Healthcare RCM
Employment Type: Full-Time
Work Mode: Work from Office
Shift: US Healthcare Shift / Night Shift

Job Summary

We are seeking experienced E&M Medical Coders with knowledge of both inpatient and outpatient Evaluation and Management coding for US healthcare providers. The ideal candidate should be proficient in reviewing clinical documentation, applying relevant coding guidelines, assigning accurate codes, and meeting established quality and productivity standards.

Key Responsibilities

• Review inpatient and outpatient medical records, physician documentation, consultation notes, progress notes, discharge summaries, and other relevant clinical records.
• Apply appropriate Evaluation and Management (E&M) coding guidelines based on the setting of care and applicable coding rules.
• Assign accurate CPT codes for outpatient E&M services, including office visits, hospital visits, consultations where applicable, and other relevant E&M services.
• Evaluate inpatient E&M services, including initial hospital care, subsequent hospital care, and hospital discharge services, as applicable to the assignment.
• Determine appropriate E&M code levels using medical decision-making (MDM), time, and applicable documentation requirements.
• Apply ICD-10-CM diagnosis coding principles and understand the distinction between inpatient and outpatient diagnosis reporting.
• Review documentation for medical necessity, completeness, consistency, and coding compliance.
• Identify documentation deficiencies and escalate coding queries through the appropriate process.
• Follow current AMA CPT guidelines, CMS requirements, official coding guidelines, and client-specific policies.
• Meet defined productivity, coding accuracy, quality, and turnaround-time targets.
• Participate in internal audits, quality reviews, feedback sessions, and refresher training.
• Maintain patient confidentiality and comply with HIPAA requirements.

Required Qualifications

• Graduate in Life Sciences, Nursing, Allied Health Sciences, or a relevant healthcare discipline; equivalent qualifications may be considered based on experience.
• Practical experience in US healthcare medical coding, preferably E&M coding across inpatient and outpatient settings.
• Strong knowledge of CPT, ICD-10-CM, medical terminology, and clinical documentation.
• Understanding of inpatient and outpatient coding conventions and applicable reporting requirements.
• Knowledge of MDM, time-based E&M code selection, medical necessity, and documentation guidelines.
• Strong analytical skills, attention to detail, and the ability to meet deadlines.
• Willingness to work in shifts aligned with US healthcare operations.

Experience & Certification

• Experience: Preferably 15 years in US medical coding, with relevant E&M coding exposure.
• Certification: CPC, CCS, or another relevant coding certification preferred, depending on the coding scope.
• Candidates with demonstrated experience in both inpatient and outpatient E&M coding will receive preference.

Preferred Skills

• Knowledge of current office/outpatient and hospital E&M coding guidelines.
• Understanding of MDM elements, time-based code selection, and documentation requirements.
• Familiarity with EHR systems, encoder tools, coding platforms, and audit workflows.
• Ability to interpret complex clinical documentation and identify coding discrepancies.
• Strong communication and teamwork skills.

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