Certified Surgery Medical Coder

Essential Functions

• Analyzes medical information from medical records.
• Accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements.
• Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes.
• Provides thorough, timely and accurate assignments of ICD and/or CPT4 codes, MS-DRGs, APCs, POAs and reconciliation of charges.
• Abstracts clinical diagnoses, procedure codes and documents other pertinent information obtained from the medical record into the electronic medical records.
• Sets out for missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations.
• Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment.
• Provides quality assurance for medical records. For all assigned records and/or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards.
• Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.

Minimum Qualifications

• Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC) in an active status or Certified Coding Specialist-Physician (CCS-P) with American Health Information Management Association or American Academy of Professional Coders is preferred.
• 1-2 years experience coding for surgery in a hospital or ASC setting.
• Must demonstrate a level of knowledge and understanding of ICD and CPT coding principles as recommended by the American Health Information Management Association coding competencies, and as normally demonstrated by certification by the American Academy of Professional Coders.

Preferred Qualifications

• Additional surgery coding experience or related education and/or experience in ASC environment preferred.
• Coding experience in Orthopedic, Spine, or Urology specialties.