Coding Appeals Specialist

St. Luke's University Health Network•Allentown, PA

About The Position

The Coding Appeals Specialist analyzes patient medical records, claims data, and diagnosis and procedure coding to verify accurate MS-DRG assignments and support appeals of proposed MS-DRG or coding changes made by insurance providers and their auditors. The role ensures that the most accurate and descriptive AHA ICD-9-CM/ICD-10-CM/PCS codes support the services and treatment rendered. The specialist conducts retrospective record reviews, develops and drafts coding appeal arguments, and collaborates with physicians, coding professionals, clinical documentation professionals, and other members of the healthcare team to resolve documentation and coding issues. The position also codes and abstracts patient records, enters coded data into EPIC, and participates in administrative hearings as needed.

Requirements

RHIA, RHIT, and/or CCS credential, with knowledge of ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure coding and MS-DRG assignment.
At least five years of coding experience in an acute-care, teaching-hospital inpatient setting.
Knowledge of anatomy and physiology, pathophysiology, and medical terminology.
Extensive knowledge of reimbursement systems and federal, state, and payer-specific regulations and policies related to documentation, coding, and, as needed, medical necessity.
Ability to understand complex disease processes.

Nice To Haves

Strongly preferred working knowledge of ICD-10-CM/PCS.
Preferred prior experience with electronic patient medical records/EPIC and the 3M encoding system.

Responsibilities

Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy.
Identify documentation and coding trends and provide feedback to Network Coding and CDMP Managers to support education of medical staff, clinical documentation professionals, and coding professionals.
Work with the physician liaison to review medical records identified by RAC/MIC/CGI/QIO and other outside auditors for DRG and coding-related issues; participate in reviews of other medical necessity issues as needed.
Develop and apply appeal arguments to defend coding and refute coding determinations made by outside payors, including CMS, Aetna, IBC, Omniclaim, QIP, and Gateway Health.
Draft appeal letters, including coding arguments, to support network coding.
Identify clinical documentation improvement issues and work independently with physicians, nurses, coding professionals, and other healthcare team members to resolve them.
Participate in Administrative Law Judge hearings as needed.
Spend approximately 20% of weekly work time coding and abstracting patient medical records according to ICD-10-CM/PCS, UHDDS, and CMS guidelines.
Use the 3M Encoder to verify and assign ICD-10-CM/PCS diagnosis and procedure codes and MS-DRG assignments.
Enter coded patient medical records into EPIC and maintain a 95% coding accuracy rate as measured through quality reviews.
Query physicians when code assignments are unclear or inconsistent, or when record documentation is inadequate, ambiguous, or unclear for coding.