Medical Records Technician (Coder)
Department of Health and Human Services
Medical Records Technician
Reviews medical records for completeness, including required identifiers, signatures, dates, and reports associated with services rendered.
Evaluates documentation for accuracy, consistency, medical necessity, and appropriate modifier usage; verifies that final diagnoses accurately reflect care provided.
Reviews provider documentation to ensure appropriate Evaluation and Management (E/M) levels and correct CPT code assignment.
Assigns and sequences ICD, CPT, HCPCS, CDT, and DSM codes based on documented diagnoses and procedures.
Ensures diagnostic and procedural terminology aligns with current medical nomenclature and official coding guidelines.
- ...Job Title Medical Records Technician Duties Makes the final determination that the record is accurate, complete, and reflects sufficient data to justify the diagnosis and warrant the treatment and end results without infringing on the decisions concerning a physician...Suggested
- Job Title Job Description Perform laboratory testing - Conduct clinical laboratory tests in chemistry, hematology, microbiology, urinalysis, immunology, serology, and blood banking, including adapting procedures for unusual specimens or situations. Evaluate test...Suggested
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