Medical Coder

The Production Medical Coder is responsible for high-volume, accurate professional coding across multiple

specialties with an emphasis on Evaluation & Management (E/M) services. This role is production-focused, with

limited non-production responsibilities, and supports revenue integrity through compliant code assignment,

provider queries when documentation clarification is required, and timely resolution of coding-related edits. Coders

are expected to work independently within established templates and workflows while meeting defined productivity

and quality benchmarks.

Key Responsibilities

Primary Responsibilities (Production-Focused)

 Perform daily production coding for professional services, including:

o Evaluation & Management (E/M)

o Office-based and procedural services

 Assign ICD-10-CM, CPT, and HCPCS codes in accordance with:

o CMS, NCCI, and payer-specific guidelines

o Specialty-specific coding rules

 Apply appropriate modifiers (e.g., -25, -59, LT/RT) as required

 Enter finalized surgical or graft application codes into AdvancedMD (AMD)

Documentation Clarification

 Issue provider queries when documentation is insufficient, unclear, or impacts E/M level selection or

compliance

 Adjust E/M codes when documentation supports a higher or lower level, with appropriate notation

 Escalate repeat documentation issues to manager (provider education handled separately by leadership)

 Participate in internal audits and feedback loops as established

Exclusions

 Coders will not be responsible for:

o Large-scale provider education initiatives

o Independent graft/biologic coding decisions (pre-approved by purchasing)

Performance Expectations

 Accuracy: ≥95% on internal audits

 Turnaround time: 48-72 hours

 Productivity: Maintains timely output for 5-8 providers, specialty-dependent

Requirements

AAPC or AHIMA certification required (CPC, CCS, or equivalent)

 Minimum 2–3 years of E/M CPT production coding experience

 Ability to code independently with minimal rework

 Strong English written fluency

Preferred:

 Experience working within AdvancedMD

 Prior experience supporting multi-provider or multi-location practices strongly preferred

 Preferred specialties:

o Podiatry

o Vascular

o Pathology

o Pain Management

o Wound care/ Skin substitute (data-entry level)

o Modifier-intensive workflows