Medical Coders – Surgery

Key Responsibilities

Surgical Coding & Documentation Review

• Review inpatient and outpatient surgical medical records, including operative reports, discharge summaries, progress notes, and physician documentation.

• Assign and sequence ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes in compliance with U.S. coding standards.

• Ensure accurate coding of principal diagnoses, secondary conditions, procedures, modifiers, and surgical approaches.

• Validate documentation supports billed surgical services and meets payer and regulatory requirements.

Quality & Accuracy

• Consistently meet productivity and quality benchmarks (target accuracy ≥ 95%).

• Participate in internal audits and quality reviews.

• Analyze audit findings, correct coding variances, and implement feedback to reduce denials and rework.

• Support denial prevention through compliant and accurate surgical coding.

Compliance & Regulatory Standards

• Maintain strict HIPAA compliance and safeguard PHI.

• Follow internal SOPs, coding policies, and compliance guidelines.

• Ensure adherence to CMS, Medicare, and payer-specific surgical coding rules.

Collaboration & Communication

• Work closely with QA teams, auditors, team leads, and operations managers to resolve coding issues.

• Communicate with clinical teams to clarify unclear or incomplete surgical documentation.

• Participate in training sessions, audits, and continuous improvement initiatives.

Continuous Learning

• Stay updated on CPT annual updates, ICD-10 revisions, and surgical coding guideline changes.

• Participate in ongoing education and professional development programs.

Qualifications & Skills

Education

• Bachelor’s degree in Life Sciences, Nursing, Pharmacy, or a related field (preferred).

Experience

• Minimum 1 year of hands-on experience in Surgery Medical Coding.

• Proven experience coding inpatient and/or outpatient surgical cases.

• Strong exposure to U.S. healthcare reimbursement and payer requirements.

Certifications (Mandatory)

• Active coding certification is required.

• Accepted certifications include:

  • CPC

  • COC

  • CCS

  • CCS-P

• Candidates without certification are not eligible.

Skills

• Strong command of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS.

• In-depth understanding of surgical anatomy, operative techniques, and documentation standards.

• High attention to detail and accuracy-driven mindset.

• Ability to manage workload under deadlines.

• Clear written and verbal communication skills.

• Strict adherence to SOPs and compliance standards.