Coder II - OR Medical | Coding-Professional

Wake Forest Baptist Health
Job Title: Coder II - OR Medical
Job ID: 4250
Full/Part Time: Full-Time
Regular/Temporary: Regular
Job Category: Advanced Practical-Clinical
Winston-Salem, NCAdvanced Practical-Clinical, Medical, Healthcare9/19/2013Coder ll - OR MedicalFull-time Regular, 40 Hours/WeekCPC or CCS certification Required OR MEDICAL CODER II 2246 FUNCTION OF JOB Under general supervision, meet directly with physicians from a variety of specialties to abstract and code hospital based (inpatient and outpatient) physician...

Job Description

Coder ll - OR Medical

Full-time Regular, 40 Hours/Week

CPC or CCS certification Required



Under general supervision, meet directly with physicians from a variety of specialties to abstract and code hospital based (inpatient and outpatient) physician surgical services; Review and discuss documentation, coding and billing of services using standard ICD diagnosis codes, CPT professional codes, internal codes, Medicare, Medicaid, managed care and commercial guidelines, regulations and requirements to provide data for billing and reimbursement.


1. Work one on one with surgeons from different specialties to review and discuss documentation and coding and billing to seek approval and release physician charges. Maintain comprehensive records of all communications regarding suggested changes.

2. Responsible for timely and accurate coding of hospital based professional services (outpatient hospital or inpatient hospital; single services or complete inpatient stays) by reading medical record documentation residing in the paper and/or electronic record to assign, sequence (primary, secondary, etc.) according to coding guidelines, and enter into the electronic system:

a. the appropriate diagnoses codes, professional service codes and modifiers.

b. the appropriate internal default codes when physicians/providers have failed to assign a level of service for Evaluation and Management Services (E&M) and/or assign and record appropriate internal 'N' type modifiers when a documentation deficiency is identified which would not support the service being billed (e.g., no Teaching Physician attestation/linking statement; no attending/Teaching Physician signature; documentation by a medical student; no documentation on a day of inpatient stay).

3. Maintain a current knowledge of ICD diagnosis codes, CPT physician service codes, internal codes (for default services and for insufficient documentation), and governmental (Medicare, Medicaid, TriCare), commercial and managed care regulations by reading relevant professional literature and by attending workshops and lectures; accrue sufficient continuing education hours to maintain national coding certification.

4. Ensure that appropriate and additional documentation is completed for:

a. the addition of Modifier 22, indicating unusual procedural effort by the physician (and potentially higher reimbursement).

b. the use of a surgical assistant, other than a resident, during a surgical procedure (as required by Medicare).

5. Work collaboratively with team members and WFUP Coding Compliance Analysts to answer questions and/or resolve issues related to documentation, coding, and billing of professional services.

6. Serve as a resource to less experienced medical coders.

7. Resolve pending charges in the TES (transaction editing system) file.

8. Provide cross coverage for hospital medical coders as assigned.

9. Perform other related duties incidental to the work described herein.


Oral and/or written instructions are received from supervision. Provide direction and guidance to less experienced personnel.


1. High school graduation or recognized equivalent.
2. Certified Medical Coder (CPC or CCS).
3. Two years of medical coding experience in a similar environment, or eligibility for internal promotion based on achieving and maintaining OR Coder level II performance criteria for six consecutive months.
4. Ability to meet and maintain performance standards for level II Medical Coder.
5. Excellent communication and interpersonal skills.
6. Ability to maintain composure in stressful environment.


1. Experience in coding of physician surgical professional services in a teaching environment; familiarity with Medicare Teaching Physician Rules.

To apply for this position, please click on the "Apply Now" button on this page. You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina 27104. You may also call our office for assistance at (336) 716-0175. Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at

It is the policy of Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.

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