You will review outpatient clinical documentation and create accurate coding input for AI training systems. Your work will help models interpret documentation, diagnoses, procedures, and encounter complexity.
Records may come from physician offices, clinics, ambulatory surgery centers, and hospital outpatient departments.
- Assign ICD-10-CM and CPT/HCPCS codes from documented clinical information.
- Apply outpatient Evaluation and Management leveling using medical decision making or total time.
- Follow outpatient diagnosis coding conventions, modifier requirements, medical necessity standards, and diagnosis-to-procedure linkage.
- Interpret office visit notes, procedure notes, operative reports, and other clinical documentation.
- Clarify ambiguous documentation through written and verbal communication.
- Give detailed feedback on coding guidelines and difficult cases to improve model understanding and project workflows.