Professional Surgical Coder
Listed on 2026-01-12
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Healthcare
Medical Billing and Coding, Healthcare Administration, Medical Records
Job Description Summary
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.
ESSENTIAL FUNCTIONS
- Codes 6-9 (number determined according to type of record coded) records per hour, consistently with 95% accuracy.
- Assigns diagnostic and procedural codes for physicians in the inpatient, outpatient, and observation setting.
- Applies sequencing guidelines based on medical record information provided according to official coding rules.
- Identifies any documentation inadequacies with provider and clarifies medical record information with courtesy and tact.
- Retrieves any and all records corresponding to surgical cases including laboratory/path reports to ensure accurate assignment of ICD-10-CM and CPT-4 codes.
- Ensures accurate, correctly coded information is entered into Epic.
- Assists with coding queries for claims appeals and resolution.
- Refer ancillary department coding questions to Professional Coding Manager.
- Utilizes professional affiliations, etc., in order to maintain current in professional developments.
- Attends all pertinent coding seminars and manager assigned training.
- Utilize all available hospital-provided electronic resources.
Equivalent to an Associate's Degree in Medical Information Technology (with coursework in medical terminology, anatomy, physiology, disease processes, ICD-10-CM coding required and prospective payment preferred).
Minimum Work ExperienceTwo to three (2-3) years in a surgical practice preferred.
Required Certifications- CPC - Certified Professional Coder
- 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.
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