Reimbursement Coding Series

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Positions assigned to these classifications are professional coders responsible for coding patient services provided in the health care setting. Reimbursement Coding Representatives are entry-level coders that code standard diagnoses and procedures. Reimbursement Coding Specialists perform complex coding in addition to auditing and analysis of coding-related activities. The Reimbursement Coding Coordinator is responsible for the overall coding operations of a unit. The Reimbursement Coding Coordinators are responsible for overseeing the daily operations of coding and working closely with patient accounts and other regulatory agencies to resolve coding issues and monitor changes in coding procedures as dictated by third-party payers and governmental reform. Employees at this level also recommend processing standards and assist with training and teaching continuous education to coding staff and clinical staff while adhering to ethical practices and third-party payer guidelines. All levels must demonstrate proficiency in coding and must be knowledgeable of the requirements of industry standards such as Medicare, Medicaid, and/or Managed Care regulations and the International Classification of Diseases (ICD-10), Healthcare Common Procedure Coding System (HCPCS), and the Current Procedural Terminology (CPT) systems of coding.

DESCRIPTIONS OF LEVELS OF WORK

Employees at this level are entry-level coders functioning under the direct supervision of a Reimbursement Coding Specialist or Coordinator. They are involved in the routine, day-to-day coding, and associated work.

A(n) Reimbursement Coding Representative typically -

1. assigns codes for ancillary, hospital services, and medical providers using standardized coding systems such as ICD-10, HCPCS and/or CPT, or verifies coding performed by clinical staff for accuracy; uses codes in referral processing for outpatient visits and procedures;
2. assists medical providers, clinic, and billing staff with coding, billing, and documentation issues;
3. maintains general reports such as tracking unbillable charges;
4. communicates with medical providers;
5. attends coding seminars;
6. under the direction of the supervisor, updates and informs clinical staff of all changes in the fee schedules;
7. composes simple correspondence to third-party payers to resolve billing/charge problems; works denials for resubmission;
8. works with the billing department to resolve and authorize adjustments on patients’ accounts; may assist with daily deposits by verifying the accuracy of payments; may review outsourced billing practices for accuracy in billing.
9. performs other related duties as assigned.

Employees at this level code for ancillary, hospital services, and medical providers to receive maximum allowable reimbursement from payers and/or are able to code more complex cases accurately for reimbursement purposes. They also perform other coding-related functions such as training, research, and auditing. They function under the general supervision of a Reimbursement Coding Coordinator or related personnel.

A(n) Reimbursement Coding Specialist typically -

1. reviews inpatient and/or outpatient documentation to assign the appropriate ICD-9-CM, ICD-10, CPT, and/or HCPCS diagnosis and procedures codes while adhering to coding guidelines;
2. keeps abreast of bulletins, newsletters, and periodicals; attends workshops to stay current on coding issues, trends, and changes in regulations governing medical record coding documentation;
3. responsible for abstracting codes and other information from the hospital system for billing and reporting purposes. Identifies and makes recommendations for coding edits;
4. assists in development of policies and procedures related to coding of medical providers, ancillary, and/or hospital services using ICD-10, HCPCS, and/or CPT;
5. tracks appeals to ensure appropriate strategies are employed and to adjust accordingly; assists in resolving day-to-day coding related issues; serves as a resource person for billing/coding purposes;
6. reviews charge tickets and/or documentation to determine accuracy of CPT and diagnosis coding;
7. prepares complex reports;
8. trains lower level staff, residents, fellows, etc.; may participate in the interviewing and hiring process;
9. reviews, analyzes and corrects or resolves claim denials;
10. performs periodic audit reviews;
11. performs duties listed in the lower level of this classification series;
12. performs other related duties as assigned.

Employees at this level work under administrative direction from a designated supervisor. They manage, direct, and monitor all coding activities for medical providers, hospital services, and/or ancillary services in a unit. They may perform audits and make recommendations based on findings. They supervise or coordinate daily activities in the coding area and direct personnel responsible for the coding.

A(n) Reimbursement Coding Coordinator typically -

1. coordinates and/or assigns workflow to assess appropriate staffing levels; assists with coding as needed;
2. maintains productivity reports;
3. develops policies and procedures related to coding; may represent department and unit in the development of institutional coding policies and procedures;
4. performs complex studies of third-party reimbursement patterns and provide recommendations to medical providers and/or administrators based on findings;
5. prepares complex reports;
6. conducts educational coding seminars;
7. researches and keeps abreast of policy changes mandated by state and federal reimbursement programs; notifies affected personnel on a routine basis;
8. researches reimbursement issues related to new services and complete feasibility studies; writes correspondence to third-party payers;
9. reviews newsletters and the Federal Register on a routine basis;
10. investigates reimbursement of patient services by third-party payers such as managed care contract reimbursement analysis; performs complex analysis of findings and recommends changes to administrators and physicians;
11. performs audit reviews, researches, and recommends needed changes to coding staff, medical providers, and/or administrators;
12. supervises lower-level staff, including interviewing, hiring, evaluating, and/or disciplining;
13. oversees and/or maintains the claims scrubber program; creates, updates, and maintains information in the electronic charge capture system and runs reports as requested;
14. resolves billing questions from patients, faculty, and staff;
15. performs duties listed in the lower level of this classification series;
16. performs other related duties as assigned.

MINIMUM ACCEPTABLE QUALIFICATIONS

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

1. High school graduation or equivalent.
2. Any one or any combination totaling 18 months from the following categories:
   1. Work experience in a healthcare setting (i.e., hospital, physician’s office, nursing home, billing agency) utilizing ICD-10, and CPT coding systems, Healthcare Common Procedure Coding System (HCPCS), and the Current Procedural Terminology (CPT) systems of coding to assign codes for services provided to patients.
   2. College course work relating to healthcare operations includes the following topics such as Medical Terminology, Human Anatomy and Physiology, ICD-10 Coding, and CPT Coding, or closely related courses.
      1. 6 semester hours equals 6 months
      2. 12 semester hours equals 12 months
      3. 18 semester hours equals 18 months
   
   Current designation as Certified Professional Coder-Apprentice (CPC-A), Certified Professional Coder (CPC) or a Certified Outpatient Coder (COC) by the American Academy of Professional Coders (AAPC) (formerly CPC-H certification) or current certification as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician-based (CCS-P) or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) by the American Health Information Management Association (AHIMA) satisfies all the requirements for this classification.
   
   KNOWLEDGE, SKILLS AND ABILITIES (KSAs)
   
   
   1. Knowledge of medical terminology.
   2. Knowledge of ICD-10 and CPT coding systems and Healthcare Common Procedure Coding System (HCPCS), and the Current Procedural Terminology (CPT) coding systems.
   3. Maintains knowledge of national standards for coding accuracy and internal standards for productivity.
   4. Maintains CEU (Continuing Education Units) as dictated by certifying body.
   5. Maintains confidentiality of patient health information at all times.
   6. Analytical ability.
   7. Mathematical ability.
   8. Organizational ability.
   9. Ability to interact with a variety of persons, including medical providers and ancillary staff.
   
   
   
   4840
   Level 2: Reimbursement Coding Specialist
   
   CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER
   
   
   1. High school diploma or equivalent.
   2. Current certification as a Certified Coding Specialist (CCS) or Certified Coding Specialist—Physician-based (CCS-P) or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) by the American Health Information Management Association (AHIMA), or current certification as a Certified Professional Coder (CPC) or a Certified Outpatient Coder (COC) by the American Academy of Professional Coders (AAPC) (formerly CPC-H certification).
   3. One (1) year/twelve (12) months of work experience comparable to that performed at the Reimbursement Coding Representative level of this series or in other positions of comparable responsibility.
   
   
   KNOWLEDGE, SKILLS AND ABILITIES (KSAs)
   
   
   1. Possession of personal attributes listed for Reimbursement Coding Representative.
   2. Skill in researching complex coding questions.
   3. Ability to supervise others.
   4. Ability to compose reports.
   5. Mathematical ability.
   6. Maintains confidentiality of patient health information at all times.
   
   
   
   4841
   Level 3: Reimbursement Coding Coordinator
   
   CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER
   
   
   1. High school graduation or equivalent.
   2. Current certification as a Certified Coding Specialist (CCS) or Certified Coding Specialist—Physician-based (CCS-P) or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) by the American Health Information Management Association (AHIMA), or current certification as a Certified Professional Coder (CPC) or a Certified Outpatient Coder (COC) by the American Academy of Professional Coders (AAPC) (formerly CPC-H certification).
   3. Three (3) years (36 months) of total work experience, two (2) years (24 months) of which are comparable to that performed at the Reimbursement Coding Specialist level of this series or in other positions of comparable responsibility.
   
   
   KNOWLEDGE, SKILLS AND ABILITIES (KSAs)
   
   
   1. Possession of personal attributes listed for Reimbursement Coding Specialist.
   2. Proficiency in researching complex coding questions.
   3. Supervisory ability.
   4. Ability to compose complex reports.
   5. Ability to develop training programs and seminars.
   6. Maintains confidentiality of patient health information at all times.
   7. Mathematical ability.