A surgery coder's job description involves reviewing patient charts to assign standardized codes (like ICD-10-CM, CPT, and HCPCS) for surgical procedures and diagnoses, ensuring accurate and compliant billing . They must maintain up-to-date knowledge of coding guidelines, collaborate with healthcare providers to resolve discrepancies, and ensure the confidentiality of patient records. Core responsibilities Coding and abstracting: Translate diagnoses, procedures, and treatments from medical records into standardized alphanumeric codes. Documentation review: Analyze patient charts and physician notes to ensure all necessary information is present and accurate for coding purposes. Compliance: Adhere to all government and insurance regulations, as well as industry guidelines and policies for coding and billing. Collaboration: Communicate with other clinical and billing staff, such as physicians, to clarify documentation and resolve any coding discrepancies or billing issues. Data analysis: Use coded data for quality assurance, tracking treatment, and other analytical purposes. Continuous learning: Stay current with annual changes in coding guidelines, regulations, and insurance policies . Required skills and qualifications Proficiency with coding systems like ICD-10-CM and CPT. Strong knowledge of medical terminology, anatomy, physiology, and disease processes. Experience with electronic medical record (EMR) systems. Excellent analytical, problem-solving, and critical-thinking skills. Attention to detail and strong focus. Cooperative and professional attitude. Relevant certification (e.g., CPC, RHIT, RHIA) is often required.