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Requisition Number
R-21350
Facility
LOC0014 - 549 Columbian Street549 Columbian Street Weymouth, MA 02190
Department Name
SHS Physician Services Admin
Status: Full time
Budgeted Hours: 40
Shift: Day (United States of America)
The Professional Surgical Coder I is responsible for the accurate and timely assignment of ICD-10-CM, CPT, and E/M codes for inpatient and outpatient services.
This role reviews clinical documentation, assigns appropriate diagnoses and procedures, identifies documentation gaps, and queries providers as needed to ensure coding accuracy, compliance, and optimal reimbursement.
The Professional Surgical Coder I collaborates with physicians and leadership to support documentation improvement and maintain high-quality coding standards.
Compensation Pay Range
$26.30 - $37.60
Essential functions
1 - Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures performed. Assigns proper ICD-10CM and CPT-4 diagnostic and procedural codes to charts and related records by reference to designated coding manuals and other reference material. a - Codes 6-9 (# determined according to type of record coded) records per hour, consistently with 95% accuracy. b - Assigns diagnostic and procedural codes for physicians in the inpatient, outpatient, and observation setting.
2 - Identifies any and/or all complications or comorbidities. a - Applies sequencing guidelines based on medical record information provided according to official coding rules
3 - Assesses the appropriateness of medical record documentation to ensure that it supports the procedure(s), diagnosis', as well as complications and/or comorbid conditions documented. Consults with the appropriate provider to clarify medical record information. a - Identifies any documentation inadequacies with provider and clarifies medical record information with courtesy and tact. b - Retrieves any and all records corresponding to surgical cases including laboratory/path reports to ensure accurate assignment of ICD-10-CM and CPT-4 codes. c - Ensures accurate, correctly coded information is entered into Epic
