The Coding Specialist is responsible for reviewing patient medical records and accurately translating diagnoses, treatments, and procedures into appropriate universal alphanumeric medical codes. This position ensures clinical documentation is accurately coded in accordance with applicable coding guidelines, regulatory requirements, and organizational standards. The Coding Specialist plays an important role in supporting accurate billing, reimbursement, medical record integrity, and compliance within a mental health and substance use treatment environment.
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Review patient medical records, clinical notes, assessments, treatment plans, and other supporting documentation to identify diagnoses, treatments, and procedures requiring coding.
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Assign accurate ICD-10-CM and applicable procedural codes based on provider documentation and established coding guidelines.
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Apply current ICD-10 coding guidelines specific to mental health, behavioral health, substance use, and psychiatric hospitals/facilities.
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Ensure codes accurately reflect the patient's documented diagnoses, services provided, and level of care.
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Review documentation for completeness, consistency, and accuracy prior to coding and billing.
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Identify missing, unclear, conflicting, or ambiguous documentation and communicate with physicians, nurses, and other clinical staff to obtain clarification when appropriate.
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Maintain a high level of accuracy and attention to detail when reviewing medical records to minimize billing, financial, compliance, and legal risks.
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Ensure coding practices comply with applicable federal and state regulations, HIPAA requirements, payer requirements, and organizational policies.
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Maintain confidentiality and security of protected health information (PHI) at all times.
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Collaborate with clinical, billing, utilization review, and administrative departments to resolve coding and documentation issues.
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Stay current with changes to ICD-10 guidelines, coding requirements, payer regulations, and applicable behavioral health and substance use treatment standards.
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Identify potential documentation and coding discrepancies and bring concerns to appropriate leadership for resolution.
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Utilize electronic health record (EHR) systems, medical billing software, and other technology necessary to perform coding responsibilities.
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Assist with audits, quality assurance reviews, and compliance activities related to medical records and coding.
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Maintain organized and accurate coding records and documentation.
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Perform other duties and responsibilities as assigned by management.
