- Review and audit clinical documentation and medical notes for accuracy and completeness.
- Assign appropriate CPT, ICD-10-CM, and HCPCS codes based on provider documentation.
- Ensure accurate coding in accordance with official coding guidelines and payer requirements.
- Identify coding errors, discrepancies, and missing documentation.
- Verify that medical notes support the assigned codes and billed services.
- Perform regular audits to ensure coding accuracy and compliance.
- Review evaluation and management (E/M) codes and ensure appropriate level selection.
- Communicate coding discrepancies and provide feedback to relevant teams.
- Maintain confidentiality of patient information in compliance with HIPAA regulations.
- Stay updated on CPT code changes, coding guidelines, and industry updates.