ESSENTIAL FUNCTIONS
• Reviews and abstracts clinical documentation from complex inpatient orthopedic and spine surgery records to assign accurate ICD-10-CM, ICD-10-PCS, DRG, POA, and discharge disposition codes.
• Independently codes high-acuity inpatient orthopedic spine surgery cases including cervical, thoracic, and lumbar procedures, revisions, fusions, instrumentation, and neurological-related musculoskeletal procedures.
• Provides real-time feedback and training for coding staff to improve coding quality and productivity.
• Applies and validates accurate MS-DRG assignments while ensuring compliance with CMS, UHDDS, Official Coding Guidelines, and payer-specific requirements.
• Identifies coding trends, documentation gaps, and reimbursement risks and communicates findings to leadership.
• Maintains productivity and quality standards while managing high-volume and high-complexity inpatient workloads.
• Serves as a coding resource and mentor to less experienced coders and assists with onboarding and education initiatives.
• Participates in policy development, coding guideline interpretation, and implementation of regulatory updates.
• Acts as a liaison between coding staff, leadership, and external stakeholders.
• Supports coding audits, denials management, appeals, and quality improvement activities as assigned.
EDUCATION
• High school diploma or GED required.
• Associate or Bachelor’s degree in Health Information Management or related field preferred.
• Must hold at least one of the following: RHIA, RHIT, CCS, or CIC. CCS strongly preferred.
EXPERIENCE
• Minimum of 4+5+ years of IP facility/hospital coding experience required.
• Minimum of 4-5 years of recent/current experience coding complex inpatient surgical cases required.
• Extensive experience with inpatient coding (ICD-10-PCS and DRG assignment) required.
• Demonstrated expertise in orthopedic surgical coding across multiple subspecialties.
• Prior experience in auditing, mentoring, or leading coding teams strongly preferred.
• Experience with denial management, appeals, and payer audits preferred.
REQUIREMENTS
• Advanced to expert level knowledge of ICD-10-CM, ICD-10-PCS, DRG, CPT and HCPCS coding systems.
• Advanced understanding of DRG and APC reimbursement methodologies, ortho anatomy and spine surgical techniques.
• Proven ability to interpret and apply complex coding guidelines and regulatory updates.
• Strong leadership skills with the ability to mentor and develop coding staff.
• Prominent level of accuracy, critical thinking, and attention to detail.
• Proficiency with coding software, EMR systems, and reporting tools.
KNOWLEDGE
• In-depth knowledge of ICD-10-CM/PCS Official Guidelines, UHDDS, CMS regulations, and payer-specific rules.
• Advanced understanding of orthopedic anatomy, surgical techniques, and musculoskeletal disease processes.
• Knowledge of compliance, audit methodologies, and revenue cycle impacts related to coding.
• Familiarity with quality programs, benchmarking, and performance improvement initiatives.
SKILLS
• Strong analytical and critical thinking skills for complex inpatient case resolution.
• Effective communication skills when interacting with physicians, CDI, and interdisciplinary departments.
• Ability to provide coding education and informal guidance to coding staff.
• Exceptional attention to detail and organizational skills.
ABILITIES
• Ability to lead coding staff in a collaborative and performance-driven environment.
• Ability to manage multiple priorities, including coding, auditing, and team support.
• Ability to maintain strict confidentiality and compliance standards.
• Ability to work independently while influencing team performance.