Pro Fee Coding Spec

Kettering Health is a not-for-profit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with high-quality care for every stage of life. Our service-oriented mission is in action every day, whether it’s by providing care in our facilities, training the next generation of health care professionals, or serving others through international outreach.

Kettering Health Miamisburg  

• Serving the residents of Warren, Butler, and Southern Montgomery counties for over 40 years.
• Kettering Health Miamisburg, formerly Sycamore Medical Center, is a full-service hospital located minutes west of the Dayton Mall on Miamisburg-Centerville Road off I-75 in Miamisburg, Ohio.
• The cornerstone services for KH Miamisburg have been Bariatric surgeries and Orthopedic care. 
• Expanded services include emergency care, sleep center, mammography, breast MRI, cardiac catheterization lab, wound center and DEXA scanning. 
• 142 bed facility
• Awarded with 100 Top Hospital by IBM Watson Health for the 10th time in 2019.
• In 2020, KH Miamisburg received an “A” from the Leapfrog Group, a national patient safety watchdog, ranking among the safest hospitals in the United States.
• Accredited by the American College of Emergency Physicians as a Level 3 Geriatric Emergency Department.
• KH Miamisburg received several awards from Healthgrades:
  • Outstanding Patient Experience Award (2017-2019)
  • America’s 100 Best Hospitals for Prostate Surgery Award (2020)
  • Joint Replacement Excellence Award (2020)

This position under the direction of the Manager of Professional Services Coding is responsible for coding compliance and EPIC WQ Reconciliation. 

KPN Pro Fee Coding Specialist

Serves as the subject matter expert ensuring coding compliance, knowledge of CMS billing rules and regulations and serves as a professional fee coding resource to network service lines.

• Demonstrates knowledge of CPT, HCPCS, ICD-10 and CMS NCCI edits
• Accurately assess documentation in EPIC EMR to assign appropriate CPT, HCPCS and ICD-10
• Reviews and researches pending and denied claims pertaining to professional fee coding, CMS NCCI edits, and/or medical necessity requirements [CMS LDC/NCD and/or payer policy]
• Demonstrate initiative for maintaining current knowledge of CPT, ICD-10 and CMS NCCI edits
• Corresponds with providers on pending claims to facilitate resolution
• Responsible for participating in departmental goals, KHN mission and implemented KHN/KPN policies
• Communicate appropriately with providers, leaders, and staff
• Researches and resolves concerns timely

Educational Requirements:

High School Diploma or equivalent

RHIT, RHIA, CCS, CCS-P, CPC or eligible specialty certification

Prior experience in professional fee coding/billing

Knowledge and Skill:

CPT, HCPCS, Modifiers, ICD-10, and CMS NCCI Edits

Medical Terminology and Anatomy & Physiology

Computer and EPIC Applications

Excellent verbal and written communication skills

Abilities:

1. Charge Review WQ [Edits]

• Reviews, researches and responds to Charge Review WQ edits pertaining to coding, CMS NCCI edits, and/or medical necessity requirements to facilitate resolution.
• Corresponds and communicates appropriately with providers on coding, CMS NCCI edits, and/or medical necessity requirements to facilitate resolution.
• Demonstrates knowledge of CPT, HCPCS, ICD-10 and CMS NCCI edits

2. Claim Edit WQ [Edits]

• Reviews, researches and responds to Claim Edit WQ edits pertaining to coding, CMS NCCI edits, and/or medical necessity requirements to facilitate resolution.
• Corresponds and communicates appropriately with providers on coding, CMS NCCI edits, and/or medical necessity requirements to facilitate resolution.
• Demonstrates knowledge of CPT, HCPCS, ICD-10 and CMS NCCI edits

3. Follow Up WQ [Denials]

• Reviews, researches and responds to Follow Up WQ edits pertaining to coding, CMS NCCI edits, and/or medical necessity requirements to facilitate resolution.
• Corresponds and communicates appropriately with providers on coding, CMS NCCI edits, and/or medical necessity requirements to facilitate resolution.
• Demonstrates knowledge of CPT, HCPCS, ICD-10 and CMS NCCI edits

4. Departmental Responsibilities

• Responsible for participating in departmental goals, KHN mission and implemented KHN/KPN policies
• Demonstrate initiative for maintaining current knowledge of CPT, ICD-10 and CMS NCCI edits
• Follow procedures pertaining to position
• Researches and resolves concerns timely