Surgical Medical Billing and Coding Processor

Financial Services

Full Time




The Surgical Medical Billing and Coding Processor will have frequent and daily interactions with internal and external clients including but not limited to Physician and Non-physician Surgical Providers. Responsibilities include primary diagnosis and procedural coding for the designated major surgical specialty areas and other major procedural areas including capture of applicable Physician Quality Reporting System (PQRS) and reconciliation of all surgical cases performed at each hospital where applicable. The Surgical Medical Billing and Coding Processor focuses their work on the detailed physician surgical chart abstraction as well as being an immediate liaison to documentation improvement and optimization of physician coding practices for compliance and revenue purposes for the providers in these areas. Surgical abstraction coding is defined as identification of codes based solely on the source documentation for CPT and ICD-9-CM respectively.



·         Primarily code from final surgical/procedural operative reports signed by the provider.

·         Responsible for billing for all Unity surgeries, obtaining prior authorizations, coordinate care for surgical patients including follow up scheduling, obtaining and scanning path reports and dictations, scheduling surgeries with the hospitals and coordinating pre-operative testing and exams.  

·         Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the primary/secondary diagnoses and procedures using ICD-9-CM and/or CPT coding conventions.

·         Support the Senior Medical Billing and Coding Specialist to respond to audit findings and make applicable coding additions or corrections.

·         Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-9-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.

·         Registers and analyzes claims in the EMR system, including insurance verification and charge entry.  Tracks and requests outstanding claims for assigned departments/facilities.

·         Coding Abstraction for each Surgical Procedure, Review of CCI Edits, LCD and NCD coverage.

·         Utilizes the EMR system to run required daily/monthly/quarterly reports on claims entered.

·         Evaluates the record for documentation consistency and adequacy.  Ensures that the final diagnosis accurately reflects the care and treatment rendered.  Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.

·         Complies with the rules and regulations of Medicare billing including (but not limited to) incident to, teaching situations, shared visits, consultations and global surgery.

·         Efficiently and accurately processes all types of claims utilizing broad based product or system knowledge to ensure timely payments are generated.

·         Maintains strict confidentiality regarding confidential conversations, documents and files.

·         Support the Senior Medical Billing and Coding Specialist to facilitates coding orientation for new providers

·         Ability to read and abstract physician office notes and procedure notes to apply correct ICD-9-CM, CPT,          

HCPCS Level II and modifier coding assignments.

·         Performs other duties as assigned.



  • GED required/Associates' degree preferred.

§  Requires 3-5 years of coding experience, with at least two of those years in surgical abstraction (physician or medical group in multi- specialty surgical practices, i.e., OB/GYN Surgery, Podiatry surgery, General Surgery, etc.).

  • CCS, CPC, CPMA, CFPC, or CPC-P certification is required.


·         Complete knowledge and understanding of UHC PM and EMR workflows.

·         Must demonstrate ability to work independently with minimum supervision in a team-oriented environment and interrelate well with individuals with diverse ethnic and cultural backgrounds and needs.

·         Advance knowledge of medical codes involving selections of most accurate and description code.

·         Extensive knowledge of official coding conventions and rules established by the American Medical Association (AMA), and the Center for Medicare and Medicaid Services (CMS) for assignment of diagnostic and procedural codes.

·         Excellent oral, written and telephone communication.

·         Working familiarity with the rules and regulation pertaining to the FQHC guidelines.

·         Ability to prioritize and manage multiple tasks with efficiency in dealing with multiple facilities.

·         Ability to handle a large volume of project receiving and researching claims.

·         Excellent computer skills, including Excel, Microsoft Word, etc.