Reviews, analyzes, and accurately codes diagnostic and procedural information that supports payment from Medicare, Medicaid and other third-party payers for professional fee services. The primary function of this position is to perform CPT, HCPCS and ICD-9 CM/ICD-10 coding for reimbursement of professional fee services. The person in this position ensures compliance with established coding guidelines, third-party payer reimbursement policies, regulatory requirements and CPN Compliance Program requirements. May be assigned to variable work areas throughout the Region. Works cooperatively as a member of the clinical staff team in the Region. Collaborates with CPN revenue cycle and CPN Compliance at the System level. *** MUST HAVE ORTHO EXPERIENCE***
1. Assigns and sequences ICD-9-CM/ICD-10/CPT/HCPCS codes based on provider submitted information and/or documentation. Assures the final diagnoses and procedures as stated by the billing provider are valid and complete and supported by documentation in the medical record. Abstracts all necessary information from the medical record (electronic and paper) to identify secondary complications and co-morbid conditions.
2. Abstracts all necessary information and assigns codes (CPT and HCPCS), which most accurately describe each documented surgical procedure and other services according to established payer guidelines and System policies. Obtain any necessary clarification of information from the provider to support coding and billing of services.
3. Reviews daily system generated error reports to correct or complete missing data elements to submit an accurate claim.
4. Determines that the final diagnoses documented by the provider are valid and complete and support medical necessity and billing criteria for payment purposes.
5. Apply correct and accurate modifiers as needed in accordance with payer guidelines.
6. Accurately and timely code all services for patient encounters in accordance with payer guidelines and CPN guidelines.
7. Analyzes provider documentation to assure the appropriate Evaluation and Management (E/M) levels are assigned using the correct CPT code.
8. Communicates information to appropriate clinic staff and medical personnel. Educates providers on documentation improvement related to billing professional fee services.
9. Collaborates with CPN Revenue Cycle and EMR to identify training needs, assess A/R rejection and denials, support appeals and provide education and feedback to providers and management for appropriate action.
10. Collaborates with CPN Compliance in accordance with System policies and as necessary for an effective compliance program.
11. Maintain appropriate level of knowledge of revenue cycle process as well as the practice management software and electronic medical record by continuous training.
12. Supports the department and CPN in achieving established performance targets and completes required training.
13. Keep abreast of CMS, Medicaid and private payer coding and documentation guideline/requirement updates and communicates to clinic staff as needed.
14. Maintain certification through appropriate organization(s).
15. Follows the CHRISTUS Provider Network guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI). Maintains strict confidentiality.