SUMMARY: Reporting to the Manager of Professional Coding, the Professional Coding Specialist is responsible for the accurate review, interpretation, and assignment of ICD-10-CM, CPT, and HCPCS Level II codes for physician and other qualified healthcare provider services. This role ensures coding accuracy and compliance with federal regulations, payer guidelines, and organizational policies to support appropriate reimbursement and minimize audit risk.
The Coding Specialist collaborates with providers, revenue cycle teams, and clinical teams to ensure complete, accurate, and compliant documentation and coding practices. Reporting to the Manager of Professional Coding, the Professional Coding Specialist is responsible for the accurate review, interpretation, and assignment of ICD-10-CM, CPT, and HCPCS Level II codes for physician and other qualified healthcare provider services.
This role ensures coding accuracy and compliance with federal regulations, payer guidelines, and organizational policies to support appropriate reimbursement and minimize audit risk. The Coding Specialist collaborates with providers, revenue cycle teams, and clinical teams to ensure complete, accurate, and compliant documentation and coding practices. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.
In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate RESPONSIBILITIES: Enters codedbstracted information into 3M 360 Finder assigning accurate APC and reviewing all coding edits appearing in 3M.
Understands and follows all National Correct Code Initiative Edits (NCCI) and follows pertinent medical necessity requirements. Resolves accounts on the claims edit database. Assigns injections and infusion codes for observation patients. Meets the minimum productivity standard mintaining an average accuracy rating of 95%. Assigns E/M, ICD-10-CM, CPT or chargemaster codes to clinic visits ensuring medical record documentation supports the code.
Should physicians have entered in diagnosis, ICD or CPT codes, ensures they are accurate and supported by documentation in the medical record. Utilizes 3M to identify and resolve NCCI edits before final billing. Reports documentation insufficiencies to the responsible physician. Follows Rhode Island Hospital Facility Coding Guidelines for adult patients and 1995 Evaluation and Management Guidelines for patients less than 18 years of age.
Monitors and resolves rejected accounts on the Claims Edit Report and e Clinical Works error reports by established timeframe researching coding conflicts including chargemaster, medical necessity and various other coding and billing issues. Refers complex coding issues to the coding validator or supervisor. Reviews pertinent outpatient uncoded reports researching and resolving old uncoded accounts and any accounts posted on report for which the charges are inappropriate.
Updates patient financial accounts in the Patient Management and Patient Accounting billing system as required. Follows established procedures for rebilling accounts. Performs related clerical duties as required. Maintains level of knowledge and expertise pertinent to the position. Compliance & Regulatory Adherence Maintain compliance with CMS regulations, National Correct Coding Initiative (NCCI) edits, Medicare Administrative Contractor (MAC) guidance, payer policies and organizational policies.
Participate in compliance initiatives to reduce coding-related denials and audit findings. Ensures compliance with HIPAA , organizational data privacy , and security policie s . Query compliance and appro