Medical Coding and Reimbursement Specialist

Definition: The medical coding and reimbursement specialist reads and interprets the medical records of patients in all types of health care facilities to obtain detailed information regarding their diseases, injuries, surgical operations and other procedures. This specialist then assigns codes using ICD-9-CM (International Classification of Diseases – 9^th Revision – Clinical Modification) and CPT (Current Procedural Terminology). They handle all components of claims processing including management of disputed, rejected and delayed claims.

Students who successfully complete this program should be able to do the following activities:
·        Read and interpret medical records of patients.
·        Accurately assign diagnostic and procedural codes according to ICD-9-CM and CPT coding systems using federal coding compliance guidelines; review the coding done on the encounter forms for accuracy.
·        Use manual and computerized encoders and groupers systems to determine Diagnostic Related Groups (DRGs), Resource Based Relative Value Scale (RBRVS), and Ambulatory Payment Classification (APCs).
·        Perform mathematical calculations for submitting insurance claims including deductible amounts, allowed amounts, secondary insurance allowed amounts and patient's responsibility.
·        Complete and electronically transmit insurance, CMS 1500 and UB 04 Medicare/Medicaid claim forms.
·        Post charge payments and write-offs on patient visits.
·        Review returned, disputed or rejected claims from Medicare and another third party payers, and problem solve.
·        Respond appropriately to patients/family questioning medical bills.
·        Act as a resource to patients, families, physicians, and office staff regarding insurance coverage for specific procedures.
·        Apply regulations for the release of confidential data, following HIPAA privacy requirements.
·        Schedule patient visits.
·        Use personal computer software programs, as well as manual and automated accounting systems.

Knowledge and skills needed by medical coding and reimbursement specialists
·        Thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for coding.
·        Medical terminology, anatomy and physiology of the human body, disease processes, and pharmacology in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. Simply locating diagnostic and procedural phrases in the coding books without applying knowledge of disease processes and procedural techniques leads to coding errors.
·        Health care delivery systems, regulations, and political reform.
·        Medical and dental reimbursement requirements and systems as well as forms completion for Medicare, Medicaid, and private insurance programs.
·        ICD-9-CM, ICD-10, CPT/HCPCS and CDT diagnostic and procedural coding systems, common coding errors, and their impact on claims processing.
·        Basics of manual and automated accounting systems and electronic claims transmission.
·        Manual and computerized systems including health information management.
·        Registration and scheduling of patients and clinicians, purchasing and monitoring of office and medical supplies, and provider correspondence.
·        Legal aspects of health care and confidentiality requirements including HIPAA privacy and security regulations.
·        Personal computer applications including word processing, spreadsheet basics, Windows, hardware and file maintenance and other topics related to computers in health care.
·        Oral and written communications using Standard English when clarifications are needed with physicians and administrators.

The Medical Coding and Reimbursement Specialist program at Shoreline Community College is approved by the American Health Information Management Association (AHIMA) as a Comprehensive Coding Program.

Graduates are eligible to write the American Health Information Management Association’s (AHIMA Certified Coding Specialist – Physician’s Office (CCS-P) examination or the entry level Certified Coding Associate (CCA) for hospital inpatient coding. They are also eligible to write the American Academy of Professional Coders Certified Professional Coding (CPC and CPC-H) examinations. The AHIMA mastery-level Certified Coding Specialist (CCS) examination is also available, although it is recommended that individuals code in the hospital setting for several years before taking this advanced credential.

Potential practice settings for the medical coding and reimbursement specialist

Graduates can be employed by physician offices and clinics, medical group practices, dental offices and clinics, managed care companies, insurance companies, hospitals and other health care providers.