OP Medical Coder

Role Overview

OP Medical Coder at NMC Healthcare. This role manages the coding, verification, and submission of outpatient and inpatient claims using ICD-10 CM, CPT, and HCPCS codes.

Role Purpose

To verify, code, and process medical claims for submission to insurance companies, analyze documentation for accuracy and compliance, and coordinate with clinical and billing teams to ensure proper reimbursement and resolution of claim discrepancies.

Key Responsibilities

Claims Submission

• Verify ICD-10 CM codes and relevant CPT/HCPCS codes on the Unified Claim Form (UCF) or discharge summary for submission to various insurance companies on a day-to-day basis.
• Upload Outpatient E-claims.
• Identify commonly used ICD codes and relevant CPT codes and compile lists.
• Identify ICD codes (Diagnosis under Exclusion) and CPT codes (not billable).
• Report variations or irrelevance in CPT codes used for services or procedures.
• Assign proper CPT/HCPCS codes for newly added services or procedures.
• Report audit findings about discrepancies in claims daily.
• Coordinate with Insurance Doctors and Billing Supervisor or Accountants for E-claim submission, resubmission, follow-up, and final sign-off.

Claims Resubmission and Review

• Review documentation by physicians in the UCF or E-Discharge Summary and identify discrepancies between the documentation and the coded diagnosis and selected CPT codes.
• Overview notes prepared for UCF or Discharge Summary to ensure all required information is present; contact the physician to obtain any missing information.
• Speak to clinicians about specialty-specific rejections, reasons for rejections, and how to avoid such rejections.
• Verify ICD-10 CM codes and relevant CPT/HCPCS codes on claims for submission to various insurance companies on a day-to-day basis.

Analysis and Reporting

• Analyze UCF documentation issues from time to time and provide reports about areas of concern in coding and claims.
• Provide reports or feedback about proper implementation of ICD/CPT coding.
• Coordinate with Insurance Companies medical teams for clarifications and other day-to-day issues.

Training and Support

• Provide training material and support to cashiers, claims processors, and nurses regarding ICD/CPT and other relevant medical coding requirements.
• Be available to Consultants for clarification regarding ICD/CPT codes.

System and Process Management

• Upload e-claims to the DHPO and/or any other portal necessary for claiming payments of direct billing claims.
• Enter codes in the software application.
• Coordinate with Billing Supervisor or Accountants for e-claim submission, resubmission, follow-up, reconciliation, and final sign-off.
• Adhere to the company's policies and procedures.
• Manage IP E-claim submission, IP and OP resubmission, and reconciliation.

Qualifications & Experience

• Bachelor's degree from an accredited college or university.
• Bachelor's degree in nursing, pharmacy, or physiotherapy is preferred.
• Certification from AAPC or AHIMA is a must.