To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Performs a variety of activities involving coding services to ensure department revenue integrity and maintains compliant billing. Accountable for troubleshooting coding related claim errors, billing rejections, medical necessity denials, and data quality reporting to CHIME and Premier. Resolves complex claim errors working with ITS, Revenue Integrity, and Billing for system resolutions. Performs a variety of activities involving coding, charging, analysis of specialty services to ensure coding revenue integrity, compliance, coding accuracy and reduce/eliminate DNB bottlenecks. Evaluates and monitors claims for accuracy prior to claim submission. Reduces the YNHHS provider liable accounts by working accounts as well as identifying the denial reasons. Works closely with managed care organizations, third party payers and registration staff, to ensure compliance to individual contract requirements in order to expedite reimbursement of accounts and protect the hospital from unnecessary financial loss. Works collaboratively with the billing and contracting department to identify and resolve all coding related policy or contract issues.
- 1. Performs outpatient coding review in claim edit, handles claims, and handles medical necessity issues.
- 1.1 Works complex claim errors and communicates with the billing team for system resolutions.
- 2. Evaluates and monitors system identified claims for accuracy prior to claim submission to ensure that it is correct as well as compliant. Interacts with other departments to maintain accurate revenue integrity and compliance.
- 2.1 Acts as an expert specialty coding resource to other coders and other hospital departments when coding questions/issues arise. Work includes knowledge in the most complex specialty outpatient coding.
- 3. Accurately assigns ICD-10-CM codes in accordance with coding/departmental guidelines. Assigns diagnostic ICD-10-CM codes in accordance with coding and departmental guidelines, maintaining no less than 95% accuracy in choice of codes, as observed by the Manager.
3.1 Sequences ICD-10-CM codes appropriately to ensure correct APC assignment and hospital reimbursement, as observed by the Manager. Correctly assigns procedure codes in both ICD10 and CPT with 95% accuracy.
3.2 Correct assignment of CPT codes with a 95% accuracy rate. Interacts with other departments (i.e. Charge Master and Pharmacy) to maintain accurate revenue integrity and compliance.
3.3 Assigns and reviews HCPCS drug coding and units charged with 100% charge review for documentation after validation.
3.4 Maintains 95% or greater accuracy in assignment of modifiers
- 4. Assists in claim reviews and denial analysis regarding all denials related to coding.
4.1 Writes effective appeal letters and coordinates with other parties to ensure that appropriate actions are taken to recover the maximum reimbursement from appeals.
4.2 Uses established re-billing, collection and follow up procedures to effectively expedite prompt resolution of denied claims. Uses proper escalation procedures both internally and externally after exhausting all avenues for timely resolution of the denied claim.
4.3 Has a complete understanding of the Provider Liable procedures in order to effectively carry out assigned duties. Demonstrates a thorough knowledge and understanding of each phase of the provider liable process and a familiarity with all systems involved.
4.4 Performs detailed analysis of YNHHS Provider Liable accounts to identify the types of issues that result in the denial of claims. Uses good planning and problem -solving methods and resourcefulness to resolve issues (including any system problems). Follows up accounts by contacting both internal and external sources to clarify pre -certification, approval, timely filing, diagnosis or other information needed to address the denial reasons and resolve the account.
4.5 Using excellent analytical and decision-making skills, manages the YNHHS Provider Liable accounts in the file. Analyzes both governmental and non-governmental denials to determine the most appropriate method to comply. Identifies which accounts are possible write -offs, re-bills or appeals and takes corrective action or refers to the appropriate parties.
4.6 Recognizes the key issues resulting in provider liable accounts and makes recommendation to improve the entire process in order to effectively reduce the number of these accounts. Looks for ways to continually to improve the process that will result in a lower incidence of provider liable accounts.
- 5. Performs a variety of departmental administrative tasks and coding related duties to assure the efficient operation of the department.
- 6. Maintains CCS/CCS-P/CPC/ COC/CRCS-I certification yearly by complying with requirements set forth by AHIMA, AAPC and AAHAM.
- 7. Identifies inconsistencies, which may indicate potential problems, which could impact on department efficiency. Makes recommendations to streamline activities and procedures to support the coding unit.
- 8. Performs all other duties or special projects requested by manager and informs the manager of any pertinent information or problems that arise to maintain a smooth operation of the department.
- 9. Performs analysis and completion of consecutive and combined accounts according to specific payer requirements
4.1 Correctly identifies and resolves Medicare consecutive accounts subjected to the 72 rule regulation for combining of related services.
4.2 Identifies Medicare cases eligible for separate reimbursement and correctly applies condition code 51 for service meeting the requirement.
4.3 Identifies Managed care cases subject to consecutive account review and resolves per the payer specific guidelines and coding rules.
4.4 Identifies and resolves Medicaid 48 hour rule and consecutive accounts eligible for separate reimbursement or subject to combining and applies rules consistent with guidelines.
Two (2) years of college or equivalent with additional training in medical terminology and anatomy. Certified Coding Specialist (CCS), Certified Coding Specialist Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) is required; RHIT, RHIA preferred. Knowledge of coding, billing, and the revenue cycle. Working knowledge of human anatomy and physiology, diseases and processes, demonstrated knowledge of medical terminology and organization of the medical record coding systems. Certified Revenue Cycle Specialist (CRCS) preferred.
Five (5) years of coding and billing related claim edits experience required (coding outpatient medical records, ICD-9, ICD-10, CPT-4, and Evaluation & Management classification systems). Previous experience with both governmental and managed care denial and appeal process as well as governmental RAC audits. Epic HB billing knowledge preferred.
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) is required; RHIT, RHIA preferred. Certified Revenue Cycle Specialist (CRCS) preferred
In-depth knowledge of medical terminology, anatomy, physiology, and disease process. Comprehensive understanding of ICD-10-CM classification systems. Expertise in governmental payment policies and regulations including medical necessity, NCCI, OCE, and MUE policies and procedures. Ability to analyze and resolve technical and medical necessity payer denials through in depth knowledge of payor policies and appeal procedures. Previous experience with clinical denials and appeals for all payers preferred.