The Coding Revenue Integrity Specialist works independently but reports to the Revenue Integrity and Pricing Strategies Manager. This specialist is responsible for monitoring the appropriateness of the code assignments, including coder assigned and chargemaster assigned codes, and reporting these findings to the Manager or designee. Serves as a contact for Patient Financial Services, responding to claim review requests pertaining to code assignment and following up as necessary. The specialist will make appropriate corrections to claims to resolve CCI and Medical Necessity edits to ensure appropriate charges and diagnosis are present on the final bill. This person will analyze the data from coding and/or charging errors and denials and in conjunction with the coding team, under the direction of the Manager, to hold education sessions with coding staff, physicians, documentation specialists, billing staff, and ancillary department charge entry staff as needed to prevent future edits and denials. He/She maintains extensive knowledge of OPPS reimbursement, including ICD-10-CM, CPT HCPCS codes, UB-04 revenue codes, modifiers, billing regulations and coding guidelines. Remains current on all coding updates and changes, as well as payor specific requirements and regulations. Serves as a resource for information or clarification on CCI edits, LCDs and NCDs, and ethical coding and documentation standards, and regulatory requirements.
1.Identifies revenue cycle issues related to OPPS reimbursement, researches/analyzes data to recommend solutions.
2.Maintains timely turnaround of all assigned work queues, denials, claim edits and charge audits.
3.Promptly processes all assigned work according to appropriate coding guidelines, billing rules, payor guidelines and regulations within timely filing targets.
4.Performs trend analyses to identify patterns and variations in coding practices and charge entry.
5.Communicates trends in departmental charging/coding issues to the Manager or department designee.
6.Maintains working knowledge of revenue cycle and aids in implementation of regulatory standards in compliance with correct coding guidelines.
7.Compares the coding and reimbursement profile of NHRMC with national and regional norms to identify variations requiring further investigation.
8.Serves as a contact person for billing staff to obtain necessary clarifications or concerns regarding CPT/HCPCS, UB-04 revenue coding, modifiers, billing regulations and coding guidelines CCI edits, LCDs/ NCDs, and ethical coding and documentation standards.
9.Maintains productivity and quality at or above standards with minimal supervision. Manages time effectively to permit completion of workload.
10.Analyzes payor regulations, including CCI edits, LCDs and NCDs, and the impact on reimbursement and coding guidelines and prepares tip sheets and reference material to share information with appropriate staff as directed.
11.Creates and conducts educational programs with the coding team and external department charge leads to improve outcomes, under the direction of the Manager.
12.Serves as a resource for information and clarification on accurate and ethical coding and documentation standards, guidelines, and regulatory requirements.
13.Promotes public relations through prompt and courteous service.
14.Fosters respect for patient/staff privacy by maintaining confidentiality in all phases of work.
15.Codes all diagnosis, treatments, and procedures according to the appropriate classification system for that category of patient encounter, and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management.
16.Abstracts patient information from records of all designated patient accounts as well as other designated patient types and enters appropriate data elements into the computerized abstracting system.