Professional Surgical Coder

South Shore Health•Weymouth, MA

6d•$33 - $45

About The Position

Under experienced leadership the Professional Surgical Coder is an advanced coding position that is responsible for accurate and timely assignment of codes to diagnoses and procedures for all outpatient and inpatient diagnostic and procedural coding. Using established department policies and procedures in conjunction with the current versions of ICD-10 and CPT-4, the Professional Surgical Coder will determine the proper diagnosis, assign co-morbidities and complications, secondary diagnoses and any HAC (Hospital Acquired conditions) documented. As well as both E/M codes and procedure codes. The Professional Surgical Coder is expected at South Shore Physician Ambulatory Enterprise to query providers when documentation requires clarification and he/she proactively works with medical leadership to address concerning documentation trends. The Professional Surgical Coder works with direct support from and under the direction of the Billing and Coding Manager to make certain their skills and knowledge remain in peak condition.

Requirements

Equivalent to an Associate's Degree in Medical Information Technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD-10-CM coding required and prospective payment preferred).
Two to three (2-3) years in a surgical practice preferred.
CPC - Certified Professional Coder OR CCS-P Certified Coding Specialist- Physician Based
Strong proficient computer and data entry skills to gather and interpret data.
Strong analytical skills to gather and interpret data.

Responsibilities

Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures performed. Assigns proper ICD-10CM and CPT-4 diagnostic and procedural codes to charts and related records by reference to designated coding manuals and other reference material.
Identifies any and/or all complications or comorbidities.
Assesses the appropriateness of medical record documentation to ensure that it supports the procedure(s), diagnosis', as well as complications and/or comorbid conditions documented. Consults with the appropriate provider to clarify medical record information.
Answers provider/clinician questions regarding coding principles,
Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature and so forth.
Works collaboratively with appropriate team members to recommend strategies for process improvement
Assists in responses to billing review requests
Abides by Standards of Ethical Coding as set forth by American Health Information Management Association (AHIMA)
Meets coding, quality and productivity standards.
Performs all job functions in compliance with applicable federal, state and local laws as well as hospital policy and procedures