Coding Compliance Specialist researches and develops the pre-certification insurance policy standards and criteria used by case management and utilization reviewers that will ensure that requested medical services are appropriate and medically necessary. Collaborates with medical professionals to resolve questions about policy development and standards. Being a Coding Compliance Specialist assigns correct ICD, CPT, or other coding assignments for medical procedures that support policy standards in claims systems. Provides expertise and solutions to users regarding the appropriate coding for claims. Additionally, Coding Compliance Specialist has broad knowledge of medical coding systems. May require an associate degree in healthcare administration, a related field, or equivalent. Requires AAPC Certified Professional Coder (CPC). May alternatively require Certified Coding Specialist (CCS) certification. Typically reports to a manager. The Coding Compliance Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Coding Compliance Specialist typically requires 2 -4 years of related experience. (Copyright 2024 Salary.com)
Description
The Medical Coding Specialist will evaluate medical records and charge tickets to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual - Clinical Modification (ICD-10-CM), and the American Medical Association’s Current Procedural Terminology Manual (CPT). The Specialist will also provide technical guidance and training on medical coding to physicians and staff. Position is on-site
· Evaluates medical record documentation and charge-ticket coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflects and supports outpatient visits and to ensure that data complies with legal standards and guidelines.
· Interprets medical information such as diseases or symptoms and diagnostic descriptions and procedures to accurately assign and sequence the correct ICD-10-CM and CPT codes.
· Reviews state and federal Medicare reimbursement claims for completeness and accuracy before submission to minimize claim denial.
· Makes recommendations for changes in policies and procedures; works with data processing staff to revise the computer master file. Develops and updates procedures manuals to maintain standards for correct coding, to minimize the risk of fraud and abuse, and to optimize revenue recovery.
· Provides technical guidance to physicians and other staff in identifying and resolving issues or errors such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, and/or codes that do not conform to approved coding principles/guidelines.
· Reads bulletins, newsletters, and periodicals and attends workshops to stay abreast of issues, trends, and changes in laws and regulations governing medical record coding and documentation.
· Educates and advises staff on proper code selection, documentation, procedures, and requirements.
· Identifies training needs, prepares training materials, and conducts training for physicians and support staff to improve skills in the collection and coding of quality health data.
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