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Medical Coder Specialist - Surgery


The Medical Coder Specialist will have frequent and daily interactions with internal and external clients including but not limited to Surgical Providers. Primary responsibilities include diagnosis and procedural coding for major surgical specialty areas and procedural areas.

The Medical Coder Specialist will focus their work on the detailed physician surgical chart abstraction as well as being an immediate liaison to documentation improvement and optimization of physician coding practices for compliance and revenue purposes for the providers.. Surgical abstraction coding is defined as identification of codes based solely on the source documentation for CPT and ICD-9-CM respectively.


  • Primarily code from final surgical/procedural operative reports signed by the provider. Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the primary/secondary diagnoses and procedures using ICD-9-CM and/or CPT coding conventions.
  • Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs (if applicable) to effectively apply ICD-9-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
  • Correlate information from "approved" supporting clinical documentation not limited to Pathology, Radiology and/or other Physician Consultations after review by the Attending Physician, wherever appropriate.
  • Provide education/training to physicians and other providers on coding and clinical documentation.
  • Consult with and educate/train physicians on coding practices and conventions in order to provide detailed coding information.
  • Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
  • Provide real-time feedback to surgical/procedural providers as it pertains to proper coding and clinical documentation of services performed.
  • Engage in provider/ department contact and education as the primary liaison for clarification of documentation and coding for defined surgical operative cases including documentation deficiencies.
  • Mentor and assists in training of other coders within the department. Participate in the development of coding policies and procedures as identified.
  • Coordinate/mentor the work of designated coding employees to ensure quality and quantity of work performed through regular audits.
  • Assist with research and development of presentation materials for continuing education programs for physician in their areas of specialization.
  • Interact with and provides high-level analysis of trends to Management, Revenue Managers and others about Coding related issues.
  • Researches and identifies trends in unbilled accounts.
  • Contacts appropriate personnel for clinical documentation inefficiencies.
  • Coordinate quality reporting measures w/ providers and revenue managers / management.
  • Collaborate with appeal and edit coders to expedient resolution of accounts. Use authorized electronic media/ systems for Physician and Non-physician Clinician documentation, Coding Abstraction.
  • Perform other related duties incidental to the work described herein.

Education and Experience:

  • Must possess one or more of the following degrees/diplomas;
    • A Bachelor degree in medical record administration
    • An Associate degree in medical record technology
    • 1 year coding diploma with completed courses in Medical Terminology, Anatomy & Physiology and extensive training in coding.
  • One or more of the following certifications and/or level of experience is required:
    • Registered Health Information Administrator (RHIA) - with no experience required
    • Registered Health Information Technician (RHIT) - with no experience required
    • Certified Coding Specialist (CCS) - with 1+ year(s) of coding experience required 
    • Certified Professional Coder (CPC) - with 2+ years of coding experience required 
    • Homecare Coding Specialist-Diagnosis (HCS-D) - with 2+ years of coding experience required 
  • Experience with ​Coding and abstracting from Surgical Notes while providing the primary communication w/specialty surgical providers in the health system assigned.
  • Requires 4+ years of coding experience, with at least 2 of those years in surgical abstraction (physician or medical group in multi- specialty surgical practices, i.e., Cardiothoracic Surgery, Neurosurgery, General Surgery, Orthopedics, etc.).
  • Extensive knowledge of coding surgical procedures, applicable modifiers in multi-specialty setting
  • Understands and apply appropriate Center Medicare Services guidelines to coding
  • Advanced ICD-9-CM & CPT-4 coding conventions experience
  • Anatomy and Physiology experience
  • Medical Terminology experience
  • Coding software familiarity
  • Effective written and verbal communication skills
  • Data entry/CRT


The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

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