- Reviews, interprets, and abstracts clinical documentation from inpatient and outpatient hospital records to assign accurate diagnosis and procedure codes (ICD10-CM, ICD-10-PCS, CPT, HCPCS).
- Codes complex orthopedic surgical cases across multiple subspecialties including spine, joint replacement, hand surgery, podiatry, and neurology-related musculoskeletal procedures.
- Applies appropriate DRG and/or APC assignment methodologies in compliance with federal and payer-specific regulations.
- Ensures coding accuracy and compliance with ICD-10-CM/PCS Official Guidelines, UHDDS definitions, CMS regulations, and other applicable standards.
- Utilizes hospital EMR and coding systems to capture all required clinical and demographic data for accurate billing and reporting.
- Collaborates with physicians and clinical staff to clarify documentation and ensure complete and accurate coding.
- Provides education and feedback to providers and staff regarding documentation improvement opportunities related to orthopedic surgical services.
- Meets or exceeds established productivity and quality benchmarks.
EDUCATION
- High school diploma or GED required.
- Associate degree in Health Information Management or related field preferred.
- Must hold at least one of the following credentials: RHIT, CCS, CIC, COC, COSC
EXPERIENCE
- Minimum of 3+ years of facility/hospital coding experience required.
- Demonstrated experience coding inpatient and outpatient hospital cases.
- Strong background in orthopedic surgical coding, including complex musculoskeletal procedures.
- Experience with DRG and/or APC assignment preferred.
- Prior remote coding experience preferred.
REQUIREMENTS
- Advanced knowledge of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding systems.
- Strong understanding of orthopedic anatomy, physiology, and surgical procedures.
- Proficiency with hospital coding software and electronic medical record systems.
- Ability to independently manage coding assignments with minimal supervision.
- Excellent attention to detail and commitment to coding accuracy and compliance.
KNOWLEDGE
- Comprehensive understanding of coding guidelines, including ICD-10-CM/PCS Official Guidelines, UHDDS, CMS regulations, and payer-specific requirements.
- Knowledge of DRG and APC reimbursement methodologies.
- Familiarity with government and commercial insurance policies.
- In-depth knowledge of musculoskeletal disease processes, surgical techniques, and related specialties (neurology, pain management, rehabilitation).
SKILLS
- Strong analytical and critical thinking skills for complex case review.
- Effective communication skills when interacting with providers and interdisciplinary teams.
- Ability to educate clinical staff on documentation and coding best practices.
- Proficiency in computer systems, coding tools, and data entry.
ABILITIES
- Ability to maintain strict patient confidentiality in compliance with HIPAA.
- Ability to work independently in a remote or office-based environment.
- Ability to manage multiple priorities while maintaining accuracy and productivity standards.
ENVIRONMENTAL WORKING CONDITIONS
- Remote or standard office environment. HIPAA compliant.