Medical Coder- Anesthesia

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A Brief Overview

This role is responsible for reviewing medical record documentation, including procedure reports, operative notes, and clinical documentation, and assigning accurate CPT, ICD-10-CM, and HCPCS codes in accordance with coding guidelines, payer requirements, and organizational policies. The position supports both inpatient and outpatient coding activities, including Evaluation & Management (E/M) level assignment, and requires expertise in Anesthesia coding and anesthesia-specific billing guidelines.

The individual will be responsible for the timely submission of charges and/or data entry of coded services to support accurate billing and revenue cycle operations. This role partners closely with providers, clinical staff, and revenue cycle teams to ensure coding accuracy, compliance, optimal reimbursement, and appropriate documentation practices.

Top Candidate Profile

The ideal candidate will bring:

• Extensive experience with Anesthesia coding, including assignment of anesthesia CPT codes, modifiers, and related ICD-10 diagnoses.
• Experience coding both inpatient and outpatient encounters across physician and facility settings.
• Strong knowledge of Evaluation & Management (E/M) leveling, including accurate code selection based on current documentation guidelines.
• Proven experience reviewing medical records, procedure reports, operative notes, and clinical documentation to accurately assign CPT, ICD-10-CM, and HCPCS codes.
• Understanding of anesthesia billing, coding compliance, reimbursement methodologies, and payer regulations.
• Experience with charge capture, charge entry, charge reconciliation, and timely submission of coded services.
• Ability to interpret complex clinical documentation and identify coding opportunities or documentation deficiencies.
• Relevant coding certification preferred (CPC, CCS, CCS-P, CANPC, or equivalent).
• Experience working within Epic and/or other electronic health record and coding platforms.
• Strong attention to detail with a demonstrated ability to maintain high levels of coding accuracy, quality, and productivity.
• Experience collaborating with providers and clinical teams to improve documentation and coding practices.

Ideal Background: A coding professional with hands-on experience in anesthesia coding, inpatient and outpatient coding, and E/M leveling who can accurately review and code complex cases, ensure timely charge submission, maintain coding compliance, and support revenue integrity initiatives while serving as a coding subject matter expert.

What you will do:

• Systematically review and analyze patient medical records to determine all appropriate diagnosis and procedures performed, and to produce coded abstract for physician billing.
• Submission of coded services for billing and or data entry of the coded services for claim submission in accordance with departmental productivity and accuracy standards.
• Review of inpatient data and reconciliation of billable services including, review of system processing and appropriate escalation and timely communication of errors and omissions and clinical documentation insufficiencies.
• Review and resolution of coding related edits and errors that impact claim submission.
• Maintaining thorough knowledge of coding and documentation requirements outlined by CPT, ICD-10 CMS and CHOP Compliance for all physician services performed.

Education Qualifications:

• High School Diploma / GED Required
• Associate's Degree Preferred

Experience Qualifications:

• At least one (1) year coding experience Required
• At least two (2) years coding experience Preferred

Skills and Abilities:

• Advanced knowledge of specialty coding.
• Advanced knowledge of ICD10, third party procedures, and requirements regarding benefit structures, insurance verification, referrals and authorizations.
• Advanced knowledge of general financial counseling and the revenue cycle.
• Familiarity with electronic health records (EHR).
• Intermediate proficiency with office software (Microsoft Office) including word processing and spreadsheet software (Word, Excel)
• Excellent verbal and written communications skills
• Excellent interpersonal skills
• Strong critical thinking / problem-solving skills
• Strong analytical skills
• Ability to maintain confidentiality and professionalism
• Ability to work independently with minimal supervision
• Ability to gather, analyze and make recommendations/decisions based on data
• Ability to convey complex or technical information in an easy to understand manner

Licenses and Certifications:

• Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC) - upon hire - Required or
• Certified Professional Coder Apprentice (CPC-A) - American Academy of Professional Coders (AAPC) - upon hire - Required or
• Certified Outpatient Coder (CPC-H) - American Academy of Professional Coders (AAPC) - upon hire - Required or
• Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA) - upon hire - Required or
• Certified Coding Specialist-Physician-Based (CCS-P) - American Health Information Management Association (AHIMA) - upon hire - Required

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must receive an annual influenza vaccine. Learn more.

Salary ranges are shown for full-time jobs. If you're working part-time, your pay will be adjusted accordingly. At CHOP, we are committed to fair and transparent pay practices. Factors such as skills and experience could result in an offer above the salary range noted in this job posting. Click here for more information regarding CHOP's Compensation and Benefits.