Role & responsibilities

1. Review inpatient medical records, including History & Physicals (H&P;), progress notes, consultation notes, and discharge summaries.

2. Assign appropriate ICD-10-CM diagnosis codes based on provider documentation and applicable coding guidelines.

3. Review and assign appropriate inpatient E&M; CPT codes, including initial hospital care ((phone hidden)) and subsequent hospital care ((phone hidden)).

4. Review discharge day management codes (99238–99239) based on documented discharge time and applicable guidelines.

5. Apply appropriate modifiers, as applicable, based on payer and coding guidelines.

6. Identify documentation gaps, inconsistencies, and missing information and raise appropriate provider queries.

7. Ensure accurate sequencing of principal and secondary diagnoses in accordance with ICD-10-CM Official Guidelines.

8. Understand and apply Medicare, Medicaid, and commercial payer-specific coding requirements.

9.



Review documentation for medical necessity and appropriate E&M; level selection based on MDM or time, as applicable.

10. Maintain productivity, quality, and turnaround-time targets.

11. Stay updated with CPT, ICD-10-CM, CMS, and payer-specific coding guideline changes.

12. Participate in internal audits, feedback sessions, and client calibration meetings.

Preferred candidate profile

- 2–3 years of hands-on experience in US Healthcare Medical Coding.

- Strong experience in E&M; Inpatient coding.

- Positive knowledge of ICD-10-CM and CPT coding guidelines.

- Understanding of inpatient admission, subsequent visits, and discharge management services.

- Familiarity with CMS and payer-specific guidelines.

- Ability to identify documentation deficiencies and formulate appropriate queries.

- Strong analytical skills and attention to detail.

- Good communication skills and ability to work independently.

📌 Medical Coder (Ahmedabad)
🏢 EhealthSource
📍 Ahmedabad