Medical Records Technician (Coder)

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.

Department of Health and Human Services