Summary of Position
- Serve as the subject matter expert on CPT (Current Procedural Terminology) and ICD-10 (International Classification of
Diseases) coding guidelines.
- Oversee the proper use of procedure and diagnosis coding to ensure CMS (Centers for Medicare & Medicaid Services) and
insurance guidelines are met and to obtain optimal claims reimbursement.
- Review, interpret and resolve complex medical coding issues requiring coder interpretation including review of claim edit
queues that cannot be resolved by external billing vendor.
Principal Accountabilities
- Review and resolve coding related edits generated in the EMR (Electronic Medical Record) requiring coding
interpretation to ensure accurate/ appropriate level of coding, timely billing and payment of medical claims.
- Assign accurate medical diagnosis and procedure codes across a wide range of services, which include evaluation and
management of anesthesia, surgical services, radiology, and other medical codes.
- Conduct coding review on provider documentation to ensure assignment of the correct ICD-10 codes and ensure
documentation is accurate, precise, and adherent to CMS guidelines.
- Perform charge audits through review of chart notes and assign correct procedure and diagnosis codes. Audits may
include peer review and Medicare charges with significant diagnosis codes.
- Maintain proficiency in all specialty coding guidelines.
- Assess performance of code review functions including optimal use of staff and systems.
- Read and interpret provider operative notes and code surgeries or procedures with appropriate CPT and ICD-10 codes
based upon the written documentation.
- Research, review, and analyze new medical procedures and corresponding CPT/HCPCS (Healthcare Common
Procedure Coding System) codes; gather input from providers.
- Recommend CPT or HCPCS codes consistent with state and federal policies.
- Review billing and EMR system to identify and analyze trends;
- Identify actual or potential issues; recommend and implement corrective actions.
- Maintain up-to-date knowledge of AMA (American Medical Association) Coding guidelines and assignment of ICD-10-
CM codes including impact and implications to healthcare providers.
- Maintain up-to-date knowledge of national coding guidelines.
- Research and maintain the collection of industry standards.
- Maintain regular and on-going communication with management and medical staff to resolve coding and associated
issues.
- Research and maintain current Medicare reimbursement policies.
- Research industry standards related to reimbursement policies.
- Collaborate with external billing company coding team to identify, troubleshoot and resolve coding related issues.
- Update physicians and managers on regulatory and coding system changes, review training needs and create and
implement training plans as needed.
- Perform other-related duties as directed, assigned or required.
Education, Training, Licenses, Certifications
- Bachelor’s Degree
- ICD-10 & CPT AAPC or AMA certification
- CCS (AHIMA Certified Coding Specialist)
- RHIT (AHIMA Registered Health Information Technician
- Certified Coding Profession (CPC) certification - Preferred
Relevant Work Experience, Knowledge, Skills, and Abilities
- 3 – 5+ years’ experience coding in a hospital, physician, or insurance environment (R)
- Additional experience/specialized certification/training may be considered in lieu of educational requirements. (R)
- Working experience with EPIC EMR. (R)
- Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations. (R)
- Knowledge of medical terminology, physiology, pharmacology, and disease processes and related procedures. (R)
- Must have working knowledge of ICD 10- impacts and implications to healthcare providers (R)
- Strong organizing, prioritizing, planning, analytical and problem-solving skills. (R)
- Strong communication skills (verbal, written, presentation, interpersonal) with all audiences. (R)
- Proficient with MS Office (Word, Excel, Power Point, Outlook, Teams, SharePoint, etc.). (R)
- Ability to handle multiple priorities and meet deadlines. (R)