ASC Business Office Staff Tasklists: Coder Tips

These tips, part of an ongoing series that identifies ASC business office staff positions and provides suggested responsibilities for auditing purposes and evaluating employee progress, focus on the Coder.

Coder                                        

1. Understands:

  • all applicable coding guidelines and requirements

  • Medicare/payer groups rules and regulations

  • anatomy

  • how to code for optimal reimbursement while remaining compliant

  • specifics for ambulatory surgery center coding

2. Abides by billing compliance regulations

3. Accesses coding reference books/software to assist in accurate coding

4. Performs all necessary coding research

5. Obtains operative/procedure report from transcriptionist or transcription service. Checks with provider regarding any delinquent dictation and follows up regularly until received

6. Requests additional documentation/clarification from provider, if necessary

7. Questions providers’ offices or business office coordinator regarding any complex/unusual cases

8. Understands concept of unbundling and heeds government regulations

9. Reads and understands procedure note

10. Codes from body of note, not just from title

11. Assigns CPT procedure code for each case

12. Assigns diagnosis codes to highest level of specificity

13. If applicable, obtains:

  • implant invoices/code

  • pathology reports

14. Appends bilateral, multiple procedure, and special requirement modifiers appropriately

15. If applicable, completes coding form and retains or scans with copy of procedure note

16. Balances accounts coded to schedule to ensure all cases completed

17. Identifies and tracks cases not coded due to lack of procedure notes, pathology reports, supply information, etc. Notifies management of any serious delinquencies

The next set of tips in this series will focus on the Charge Poster/Billing Specialist. Access other tips in this series on ASC staff tasklists.

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