Evaluation and Management Coder (E/M)

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Cancer hospital is seeking an E/M Coder for a 6 + months contract (most likely would extend.


Description

The Evaluation and Management (E/M) Coder is responsible for accurately assigning codes for professional and/or facility Evaluation & Management services rendered in both inpatient and outpatient hospital settings, including observation, emergency department, and clinic encounters. This position ensures compliance with official coding guidelines, payer-specific regulations, and organizational policies to support accurate reimbursement, minimize audit exposure, and promote revenue integrity across the continuum of care.

Key Responsibilities

  • Review provider documentation to determine appropriate E/M level assignments for inpatient (initial, subsequent, discharge) and outpatient (new, established, observation, and consultation) encounters.
  • Accurately assign E&M procedure and diagnosis codes according to AMA, CMS, and facility-specific E/M guidelines, including time-based and medical-decision-making criteria.
  • Analyze provider documentation for medical necessity, completeness, and compliance with organizational and regulatory requirements.
  • Ensure coding accuracy for hospital-based physicians, including hospitalists, specialists, and advanced practice providers.
  • Perform E/M coding for observation, emergency department, same-day surgery, and outpatient clinic services as assigned.
  • Reconcile documentation and charges between professional and technical components to ensure billing integrity.
  • Collaborate with providers, clinical departments, and compliance teams to resolve documentation deficiencies and educate staff on best practices.
  • Monitor and resolve E/M-related coding edits, claim denials, and payer rejections in a timely manner.
  • Participate in internal and external coding audits, assist with corrective action plans, and maintain audit-ready accuracy standards.
  • Stay current with updates to E/M documentation rules, ICD-10-CM guidelines, and payer requirements, ensuring continuous compliance.

Qualifications

Education:

  • High school diploma or equivalent required.
  • Associate’s or bachelor’s degree in Health Information Management, Nursing, or related field preferred.

Experience:

  • Minimum of 2 years of recent E/M coding experience in a hospital environment, including both inpatient and outpatient settings.
  • Experience coding for multi-specialty hospital-based providers strongly preferred (e.g., internal medicine, oncology, emergency medicine, cardiology, or surgery).

Certification:

  • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential required.
  • Certified Evaluation and Management Coder (CEMC) preferred.

Skills and Competencies

  • Advanced knowledge of CPT, ICD-10-CM, HCPCS, and 2021 E/M guidelines for both professional and facility coding.
  • Comprehensive understanding of Medicare E/M leveling, observation coding, and split/shared visit rules.
  • Strong analytical skills and attention to detail. Confidence directly reviewing provider documentation, and determining appropriate and specific code assignment, based on the content of the clinical documentation sourced from hospital information systems and EHR platforms
  • Effective communication skills with physicians, compliance staff, and revenue cycle teams.
  • Commitment to confidentiality, integrity, and adherence to federal and state regulatory standards.

Performance Indicators

  • Maintain ≥95% E/M coding accuracy, while completing a requisite number of encounters per working hour. Inpatient and outpatient productivity benchmarks are required.
  • Reduce E/M-related denials through proactive documentation clarification and follow-up audit.

Experience and confidence coding oncologic surgical procedures for any one of these:
- Head & Neck (laryngectomy, flap reconstruction, neck dissection)
- Urology (prostatectomy, cystectomy, nephrectomy)
- Plastic/Reconstructive Surgery (flap/graft, breast reconstruction, Mohs closures).
-Experience with robotic procedures is a plus.

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