Profee - Medical Coder (Out Patient)

Position: ProFee Medical Coder (Outpatient)

Job Summary:

Under the supervision of the Operations Manager, the ProFee Medical Coder is responsible for assigning accurate diagnosis and procedure codes to patient medical records and abstracting clinical data into the facility's computer system. The role primarily focuses on Professional Outpatient (ProFee OP) coding but may include other patient types depending on business needs.

The coder must accurately apply ICD-10-CM (diagnosis), CPT, ICD-10-PCS, and HCPCS codes, ensuring compliance with official coding guidelines. This position supports proper billing, reporting, and statistical analysis.

Key Responsibilities:

1. Abstract, code, and sequence diagnoses, procedures, and treatment modalities for inpatient and day surgery cases, when applicable.

2. Review provider documentation to determine principal diagnosis, secondary conditions, co-morbidities, complications, and surgical procedures.

3. For Outpatient and Professional services:

   • Assign appropriate ICD-10-CM, CPT, and HCPCS codes.

   • Assign accurate Ambulatory Payment Classifications (APC) for facility coding.

   • Perform compliance reviews following official coding guidelines, facility instructions, payer rules, and physician directives.

4. Compose compliant queries to providers to clarify or improve clinical documentation and coding accuracy.

5. Enter coded data into the encoder and abstracting system using information extracted from source documents.

6. Report daily productivity and any issues to the immediate supervisor.

7. Identify and escalate improper coding or documentation concerns.

8. Maintain confidentiality of all patient information in accordance with HIPAA and facility policies.

Qualifications:

• Bachelor's Degree in Medical Records, Allied Medical Fields, or equivalent education and relevant clinical work experience.

• At least 1 year of experience in Professional Outpatient (ProFee) medical coding.

• Strong knowledge of:

  • Medical terminology and coding guidelines

  • ICD-10-CM, CPT, HCPCS, DRGs, and APCs

  • Encoder and abstracting systems

• Proficient in computer applications and electronic health records (EHR).

• Excellent analytical, communication, and customer service skills.

• Strong attention to detail and ability to interpret handwritten clinical documentation.

Certifications (Required):

• AAPC: CPC, COC, or CIC

• AHIMA: CCA, CCS-P, or CCS