Job Description

• 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.