SDS Coder
The SDS coder is responsible for reviewing medical records for outpatient, or same day, surgical procedures, and assigning appropriate diagnostic and procedural codes (CPT and ICD-10) to ensure accurate billing and reimbursement.
Duties and Responsibilities:
- Apply appropriate coding classification standards and guidelines to medical record documentation for accurate coding.
- Submit necessary provider queries to resolve documentation discrepancies.
- Perform quality assessment of records, including verification of medical record documentation.
- Review appropriate charges and make changes or recommendations based on the documentation.
- Responsible for researching errors or missing documentation from medical records to provide accurate coding processes.
- Abstracts and assigns the appropriate ICD-10-CM and CPT codes for all diagnoses and procedures performed in the outpatient and surgical settings as applicable.
Knowledge, Skills, and Abilities:
- Must have facility outpatient surgery and observation experience and ideally be exposed to observation hours, injections, anesthesia, and infusion code assignment.
- Must be able to pass a coding assessment.
- Must be proficient in Microsoft Office, including Outlook, Excel, and Teams.
- Ability to multi-task and have excellent communication skills.
- Must meet and maintain a 95% quality accuracy rate and productivity standards.
- Must be able to apply official coding guidelines, NCCI edits, CPT Assistants, and Coding Clinics.
- Must have experience working in a remote environment.
Work Experience, Education, and Certifications:
- AHIMA/AAPC Credentials
- Five or more years of Auditing experience
- Physician surgery coding experience preferred
100% Remote