CODING COMPETENCIES REVIEWED WILL INCLUDE:

v HEALTH INFORMATION DOCUMENTATION

Ø Interpret health record documentation to identify diagnoses and conditions for code assignment

Ø Interpret health record documentation to identify procedures or services for code assignments

Ø Determine if sufficient clinical information is available to assign one or more diagnosis codes

Ø Determine if sufficient clinical information is available to assign one or more procedure or service codes

Ø Consult with physicians or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous information

Ø Consult reference materials to facilitate code assignment

Ø Identify the etiology and manifestation(s) of clinical conditions

v CODING

Ø Assigning ICD-9-CM code by applying “Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office)”

Ø Interpret ICD-9-CM conventions and formats

Ø Interpret CPT and HCPCS guidelines

Ø Assign CPT code(s) for procedures and/or services rendered

Ø Assign codes to identify E&M services

Ø Recognize if an unlisted procedure must be assigned

Ø Exclude from coding those procedures that are component parts of another procedure code

Ø Code for professional vs. technical component when applicable

Ø Assign HCPCS codes

Ø Append modifiers to procedure or service code when applicable

v REIMBURSEMENT METHODS AND REGULATORY GUIDELINES

Ø Global Surgical package

Ø Bundling and unbundling guidelines (NCCI)

Ø Interpret health record documentation to identify procedures or services for code assignments

Ø Apply reimbursement methods for billing

Ø Appropriate link of diagnosis to procedure

Ø Evaluate payer remittance or payment

Ø Interpret NCDs or payer policies

Ø Process claims denials and/or appeals

v DATA QUALITY

Ø Validate assigned diagnosis and procedure codes

Ø Validate assigned E&M codes

Ø Assess the quality of coding and billing

Ø Verify the data on the claim form

Ø Validate the accuracy of the required data elements

Ø Conduct coding and billing audits for compliance and trending

Ø Determine educational needs for physicians and staff on reimbursement and documentation rules and regulations

Ø Participate in the development of coding and billing policies and procedures

Ø Evaluate payer remittance or payment