Inpatient Surgical Coder

Inpatient Surgical Coder

Assigns ICD-10-CM and ICD-10-PCS codes for inpatient surgical and procedure-based records. Ensures accurate DRG assignment reflecting procedures performed and patient acuity. Reviews documentation to validate procedural coding, sequencing, and clinical alignment. Maintains productivity and turnaround time standards to support DNFB reduction and revenue cycle performance. Applies coding guidelines, regulatory requirements (IPPS, CMS) and payer rules to ensure compliant coding practices. Identifies documentation gaps related to procedures and collaborates with CDI for clarification when appropriate. Incorporates audit findings and education into daily coding practice to ensure accuracy and consistency. Reviews documentation to identify MCC/CC capture opportunity. Participate in quality reviews and respond to audit feedback and performance improvement initiatives. Maintains knowledge of coding updates, PCS guidelines, and regulatory changes. Performs other duties as assigned.

Ability to interpret clinical documentation and its impact on coding and DRG assignment [Required]. Knowledge of ICD-10-CM coding, low acuity procedures, and inpatient reimbursement (IPPS) [Required]. Understanding of CDI processes and documentation requirements [Required]. Ability to identify coding and documentation risks [Required]. Ability to write compliant queries [Required]. Strong analytical and problem-solving skills [Required]. Effective communication and collaboration across clinical, CDI, and coding teams [Required].

High School Grad or Equiv [Required]

4+ years acute care hospital coding including heavy PCS coding of complex surgeries, or 4 years of hospital coding and completion of the AdventHealth inpatient surgical coding training [Required]

Certified Coding Specialist (CCS) [Required] OR Registered Health Information Administrator (RHIA) [Required] OR Registered Health Information Technician (RHIT) [Required] OR Certified Professional Coder (CPC) [Required]