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Medical Coder (Outpatient)

Medical Coder (Outpatient)

This checklist was electronically signed on September 12, 2026

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

PATIENT RIGHTS

Communicate and obtain information while respecting patient rights, privacy, and confidentiality of information by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Involve the patient and family and respect their role in determining the nature of care to be provided
Meet patients' and families' needs regarding communication, including interpreter services
Provide accurate information to patients and families promptly

COMMUNICATION

Communicate with patients and their companions in a courteous manner
Understand the chain of communication, who to contact, and when
Listen actively to patient concerns and address them appropriately.
Cultural Sensitivity and Language Skills

TECHNICAL KNOWLEDGE

Anatomy
Medical Terminology
CPT codes
ICD-10 codes
Coding Guidelines for ICD-10-CM and CPT
HCPCS codes
Modifiers

COLLABORATIVE SKILLS

Collaborate with billing department to ensure all bills are satisfied in a timely manner
Communicate with insurance companies about coding errors and disputes
Submit statistical data for analysis and research by other department
Contact physicians and other healthcare professionals with questions about treatments or diagnostic tests given to patients with regard to coding procedures
Consult medical specialists for further clarification and understanding of items on patient charts to avoid any misinterpretations
Evaluate and re-file appeals of patient claims that were denied
Develop good client relationship in the course of duty
Provide accurate answers to queries on coding

GENERAL SKILLS

Comply with all legal requirements regarding coding procedures and practices
Conduct audits and coding reviews to ensure all documentation is accurate and precise
Analyze patient charts carefully to know the diagnosis and represent every item with specific codes
Ensure that codes tally with doctors’ diagnosis
Assign and sequence all codes for services rendered
Collect health information as documented by medical specialists and code them appropriately
Advocate for patients where their medical history is needed as evidence
Be updated about new coding rules as codes change from time to time
Collect and distribute coding related information and billing issues

ELECTRONIC DOCUMENTATION

Allscripts
Care360
Cerner(Oracle)
CPSI
eCLinicalWorks
Eclipsys
EPIC
MACLAB
McKesson/Paragon
Meditech
PACS
Quadramed
Soarian

AGE-SPECIFIC COMPETENCIES

Newborn/Neonate (birth-30days)
Infant (31 days-1 year)
Toddler (1-3 years)
Preschooler (3-5 years)
School-age children (5-12 years)
Adolescents (12-18 years)
Young adults (18- 39 years)
Middle adults (39- 64 years)
Older adults (64-79 years)
Elderly adults (80+ years)