Objective :

Deploy certified medical coders to ensure the accurate and compliant assignment of diagnosis and procedure codes, directly improving reimbursement accuracy and minimizing claim denials.

Key Responsibilities :

Accurate Code Assignment

Purpose: To translate provider documentation into appropriate billing codes that reflect services rendered and medical necessity.

Tasks:

  • Review clinical documentation from encounters, surgeries, diagnostics, and procedures.
  • ICD-10-CM codes for diagnoses
  • CPT/HCPCS codes for services and procedures
  • Modifiers (e.g., -25, -59, -TC) as appropriate
  • Validate place of service (POS) and provider type to ensure billing compliance.

Certified Coding Professionals :

  • Utilize certified coders (e.g., CPC, CCS, CRC) who are trained in:
  • Specialty-specific coding (e.g., cardiology, ortho, behavioral health)
  • Payer-specific requirements
  • Current procedural and diagnosis coding updates (CPT/ICD annual changes)
  • Maintain ongoing education to ensure coders are up to date with CMS, AMA, and payer policy changes.

Coding Audits & Quality Assurance :

Purpose: To validate accuracy, reduce compliance risk, and support optimal reimbursement.

Responsibilities :

  • Perform pre-bill audits to check for:
  • Overcoding, undercoding, or unbundling
  • Documentation insufficiencies
  • MUE/NCCI edit conflicts
  • Conduct post-bill audits on high-risk claims or denial patterns.
  • Generate coding error reports to identify trends and provide feedback to providers.

Denial Prevention & Revenue Optimization :

Purpose: Reduce downstream denials and ensure maximized reimbursement.

How Coding Supports This :

  • Ensures medical necessity alignment with payer policies
  • Prevents billing errors that cause payer rejections or audits
  • Facilitates clean claims for faster processing and fewer resubmissions

Our Best Practices :

  • Maintain a coding guidelines manual for each specialty and payer.
  • Implement a dual-review process for high-dollar or surgical claims.
  • Provide feedback loops between coders and providers to improve documentation.
  • Use coding compliance software to flag problematic code combinations or missing links.

Why It’s Important :

Proper coding is critical to the health of the revenue cycle. Certified coders not only protect against revenue loss and compliance issues but also ensure that services are billed accurately, fairly, and in accordance with payer policies.