Coding Analyst

RESPONSIBILITIES

• Ability to analyze and interpret medical records and codes for appropriate diagnosis and procedures as it relates to coding
• Ensure accurate coding by following established principles and guidelines
• Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-9 codes for billing, internal and external reporting, research and regulatory compliance
• Pairs CPT/ICD9 codes for accurate billing and maximum reimbursement
• Participates in educational training to stay current with coding requirements as set by Department and/or Company.

QUALIFICATIONS

• 3-5 years’ experience in medical coding, hospital setting preferred
• Certified RHIA, RHIT, and/or CCS is preferred
• Proven ability to learn new software programs
• Possess extensive knowledge of medical terminology, the human disease process, anatomy and physiology
• Exhibit time management, organizational, verbal and written communication skills
• Maintain strong skills in diplomacy, professionalism and trustworthiness

Essential Key Responsibilities

• Analyze Denials: Review remittance advices (ERAs) and explanations of benefits (EOBs) to identify the specific root causes of coding-related denials.
• Audit Documentation: Evaluate electronic health records (EHR) against provider documentation to verify coding accuracy for CPT, ICD-10-CM/PCS, and HCPCS Level II systems.
• Correct and Resubmit: Modify erroneous claims using proper modifiers (e.g., -25, -59), corrected diagnosis linking, or updated procedure codes for immediate resubmission.
• Cross-Track Auditing: Identify root causes of denials for both hospital facility claims (DRG, APC, status changes) and professional fee claims (E&M levels, teaching physician rules).
• Track Trends: Monitor systemic denial patterns by specific payers or departments and report findings to management to prevent future revenue leakage.
• Multi-EHR Navigation: Seamlessly switch workflows between diverse Electronic Health Record (EHR) platforms and clearinghouses to research claim histories.
• Complex Appeal Writing: Draft evidence-based appeal letters addressing clinical medical necessity, bundling issues, and complex NCCI edits.
• Claim Correction: Apply appropriate CPT, ICD-10-CM/PCS, HCPCS Level II codes, and complex modifiers (e.g., -25, -59, -78, -GC) to resubmit optimized claims.
• Virtual Provider Inquiry: Conduct electronic and video-based queries with clinicians to clarify ambiguous documentation across various departments.
• Query Providers: When appropriate, collaborate with physicians and clinical staff to clarify ambiguous documentation and secure missing charts needed to overturn claims.
• Remote Productivity: Meet strict daily quotas for claim reviews and appeal submissions while maintaining a minimum 95% coding accuracy rate.
• Payer Policy Tracking: Stay updated on evolving CMS regulations, monitor evolving LCDs, NCDs, and private payer reimbursement policies affecting both institutional and professional claims and report findings to management to prevent future revenue leakage.
• Identify Denial Trends: Track recurring denial patterns by payer, provider, or specialty to pinpoint systemic workflow issues.
• Educate Clinical Staff: Provide feedback to physicians and documentation specialists regarding gaps in medical charts that lead to preventable denials.
• Check Modifier Usage: Investigate whether modifiers were applied incorrectly, omitted, or if they lack supporting documentation in the medical record.
• Assess Medical Necessity: Evaluate if the documented diagnosis codes adequately justify the necessity of the performed procedures according to payer policies.

Required Qualifications & Skills

• Certification: Dual credentials preferred, or at least one active core credential from AAPC (CPC, COC) or AHIMA (CCS, CCS-P, RHIT, RHIA).
• Experience: Minimum 3–5 years of medical coding experience, with at least 2 years explicitly handling both inpatient/outpatient facility and professional fee denials.
• EHR Versatility: Proven track record of high adaptability using multiple EHR systems (e.g., Epic, Cerner, Meditech, eClinicalWorks, SFM) and encoder tools (e.g., 3M).
• Remote Setup: Must possess a private, HIPAA-compliant home office with high-speed internet access.
• Self-Management: Strong time-management skills to work independently without direct, face-to-face supervision.

Performance Metrics (KPIs)

• A/R Recovery Rate: Dollar value of successfully overturned denials across both hospital and physician lines.
• Cross-Functional Accuracy: Maintaining an auditing error rate under 5% across both UB-04 and CMS-1500 standards.
• Turnaround Efficiency: Volume of priority denials researched and resubmitted within strict payer timely-filing windows.
• Adherence to Company Policies: Achieves 100% adherence to established standard operating procedures (SOPs), including daily remote check-ins, mandatory HIPAA home-office security audits, and documenting all denial notes inside the internal tracking tool before logging off.

Frequent Denials

1. CO-16: Claim/Service Lacks Information or Has Billing Errors

• What it means: The payer cannot process the claim because essential information is missing, incomplete, or formatted incorrectly.
• How to fix it: Look up the paired Remittance Advice Remark Code (RARC) on the explanation of benefits to identify the exact missing data field. Coders will supplement missing details—such as a missing National Provider Identifier (NPI), an incorrect patient date of birth, or an unlisted social security number—and resubmit the corrected claim.

2. CO-11: Diagnosis is Inconsistent with the Procedure

• What it means: The billed ICD-10-CM (diagnosis) code does not clinically support or match the CPT/HCPCS (procedure) code submitted.
• How to fix it: Cross-reference the patient's medical chart and operative report to check if a transposition typo occurred. If the documentation supports a more specific or accurate diagnosis code that validates the treatment, update the ICD-10 code to the highest level of specificity and resubmit the claim.

3. CO-50: These Services are Not Deemed Medically Necessary

• What it means: The payer determined that the treatment or service provided was not required or appropriate based on their medical coverage policies.
• How to fix it: Review the payer's specific Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs) for that procedure. If the physician's clinical notes strongly support the necessity of the service, compile an appeal packet containing clinical documentation, test results, and a formal letter written by the provider to overturn the denial.

4. CO-97: The Benefit for this Service is Included in the Payment/Allowance for Another Procedure

• What it means: The payer "bundled" the service, meaning they view it as part of a larger primary procedure performed on the same day rather than a separate billable service.
• How to fix it: Check the National Correct Coding Initiative (NCCI) edits to see if the services are unbundled under certain conditions. If the documentation shows the procedure was distinct, independent, or performed on a separate anatomical site, append the appropriate modifier (such as Modifier 59 or XS) to differentiate it and resubmit.

5. CO-18: Duplicate Claim/Service

• What it means: The payer received a claim that matches an identical, previously processed claim in their system for the same patient, date of service, provider, and codes.
• How to fix it: Check the facility's internal billing history. If it was a system glitch that resent the same bill twice, void the duplicate and take no further action. However, if the patient legitimately received the exact same procedure twice on the same day (e.g., multiple X-rays), append a repeat procedure modifier (such as Modifier 76 or 91) to clarify that it is not a duplicate and resubmit.