The function the coders perform is after the claim has been processed by the payer(Insurance carrier) and has denied or underpaid due to a coding reason, the claim is referred to the coding staff. The coding staff reviews the bill against the medical records to ensure the claim has been coded correctly or if there are any suggestions they can provide to the client that will help mitigate the denial/underpayment.
Example reasons why a payer would deny a bill:
o Medical bill was denied because the code was missing a modifier.
o Medical bill was denied because the codes listed on the bill did not match the services documented in the medical records. (This is where the experience abstracting comes in)
o Medical bill was under paid because one charge denied as the payer considered it a bundled procedure.
If the bill is coded correctly, then the Coding staff provides the internal Revenue Specialist with nationally sourced documentation to show why the bill and/or charge should be paid. If changes need to be made to the claim, the staff sends a corrected claim request to their clients recommending appropriate changes to the codes. Due to compliance purposes, they only make suggestions/recommendations to their clients, and it is up to the client whether or not they choose to make adjustments to their bill and send them a corrected claim.
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Experience with Workers' Compensation, Veterans, Commercial and Out of State Medicaid claim types
CARC and RARC coding experience
Billing experience
Aware of the appeals process in the billing world
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.