Coder- Surgery Center

Description

Position Summary:

The Surgical Coder in an Ambulatory Surgery Center (ASC) is responsible for accurately assigning ICD-10-CM, CPT, and HCPCS Level II codes to surgical and procedural services based on thorough review of patient medical records. This role ensures coding compliance with current healthcare regulations and supports timely, accurate billing and data reporting. The ideal candidate has strong knowledge of surgical procedures, anatomy, and medical terminology, and is comfortable collaborating with clinical and administrative teams. This is a non-exempt position. 

Key Responsibilities:

• Assign appropriate diagnosis and procedure codes (ICD-10-CM, CPT, HCPCS) in accordance with documentation and regulatory requirements
• Analyze patient medical records, operative reports, and other clinical documentation to ensure completeness and accuracy in coding.
• Work closely with surgeons, nurses, and billing staff to clarify documentation and resolve coding discrepancies.
• Follow official coding guidelines, payer policies, HIPAA regulations, and facility-specific coding and billing protocols.
• Extract essential data elements from clinical documentation to support accurate billing and reporting.
• Participate in internal and external audits, monitor coding productivity and accuracy, and review bill hold reports as needed.
• Stay current with changes in coding rules, payer guidelines, and industry standards through ongoing education and training.
• Respond to inquiries related to coding and billing from internal departments and external stakeholders.

Requirements

• Education:
  High school diploma or GED required. Associate’s or Bachelor’s degree in Health Information Management or related field preferred.
   
• Certification:
  Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification required.
   
• Experience:
  Minimum of 2 years of surgical coding experience in an ASC or outpatient setting preferred.
   
• Skills:
   
• Strong understanding of medical terminology, anatomy, and surgical procedures
   
• Excellent attention to detail and accuracy
   
• Familiarity with EHR systems and coding software
   
• Effective written and verbal communication skills
   
• Ability to work independently and manage time effectively