Assigns outpatient diagnosis and procedure codes from clinic and office records and checks E&M levels against official guidelines. Suits certified professional coders with outpatient experience who can explain tricky coding cases clearly in writing.
About the role
Location: United States, Remote
micro1 is engaging Medical Coders to contribute their expertise to a dynamic project for a valued customer. In this role, you'll apply your outpatient coding expertise to help train next-generation AI systems. Your work will shape how models learn, reason, and perform through high-quality, real-world input. No prior experience in AI is required. Your domain knowledge is what matters.
Scope of Work
- Annotate and review outpatient medical records (physician office, clinic, ambulatory surgery, and hospital outpatient encounters), ensuring accurate assignment of ICD-10-CM and CPT/HCPCS codes based on documentation.
- Apply Evaluation & Management (E&M) leveling to outpatient visits using official guidelines (medical decision making or total time) to validate and enrich datasets.
- Apply outpatient-specific coding conventions, including diagnosis coding guidelines for outpatient services, modifier usage, medical necessity, and linking diagnoses to procedures.
- Collaborate with project stakeholders via written and verbal communication to clarify requirements and resolve ambiguities in clinical documentation.
- Provide high-quality feedback on coding guidelines and edge cases to improve project workflows and model understanding.
Preferred Qualifications
- Active AAPC Certified Professional Coder (CPC) certification is required.
- Comprehensive understanding of ICD-10-CM and CPT coding systems and outpatient E&M leveling guidelines.
- Hands-on experience coding in outpatient settings (e.g., primary care, specialty clinics, ambulatory surgery centers, outpatient hospital departments).
- Experience with diverse clinical documentation types and associated coding challenges, such as office visit notes, procedure notes, and operative reports.
- Proficiency with both written and verbal communication, with a strong attention to clarity and detail.
- Access to up-to-date official ICD-10-CM, CPT, and HCPCS Level II coding books, as well as E&M guidelines.
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