Facility Coder II

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.