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Health Information Management Professional Fee Coder

Competency-Based Apprenticeship
Sponsoring Company:
American Health Information Management Association (AHIMA)
O*Net Code
Rapids Code
Req. Hours
Jul 16, 2021
Jul 16, 2021

Competency-Based Skills

11 skill sets | 11 total skills
Use and maintain electronic applications and work processes to support clinical classification and coding (for example, encoding and grouping software)
Demonstrates understanding in use and application of encoder and grouper software
Apply outpatient diagnosis and procedure codes according to current nomenclature and demonstrate adherence to current regulations and established guidelines in code assignment (focus on assignment of first listed diagnosis, and sequencing as well as other clinical coding guidelines)
Audits indicate appropriate code and sequencing use following regulations and guidelines
Ensure accuracy of diagnostic/procedural APC (Ambulatory Payment Classification) system
Audits indicate accuracy of APC assignment
Validate outpatient coding accuracy using clinical information found in the health record
Audits indicate accuracy of diagnostic and procedural coding
Use and maintain applications and processes to support other clinical classification and nomenclature as appropriate to the work setting (e.g., DSM V (Diagnostic and Statistical Manual of Mental Disorders), SNOMED-CT (Systematized Nomenclature of Medicine - Clinical Terms)
Identifies correct coding nomenclature for patient type and location
Resolve discrepancies between coded data and supporting documentation. Communicates with providers to ensure appropriate documentation.
Creates compliant physician queries
Apply policies and procedures for the use of clinical data required in reimbursement and outpatient prospective payment systems (OPPS) in healthcare delivery as well as changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care, etc.
Adheres to national, regional and facility-specific requirements for accurate reimbursement by payer type
Support accurate billing through coding, chargemaster, claims management, and bill reconciliation processes
Reviews codes identified manually and by the chargemaster to ensure compliant billing
Use established guidelines to comply with reimbursement and outpatient reporting requirements such as the National Correct Coding Initiative and others
Follows coding edits for compliance with NCCI
Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment systems
Participates in coding audits
Participate in compliance (fraud and abuse), HIPAA (Health Insurance Portability and Accountability Act of 1996), and other organization specific training.
Attends required compliance training

Technical Instruction

Introduction to Coding Basics - 20 req. hrs
Describe the health record and standard health record formats
Identify organizations that direct health record format
Recognize basic elements of health record documentation
Understand the resources used to assign diagnostic and procedure codes
Understand CPT structure and coding conventions
Identify the sources of documentation that generate physician codes and charges
Identify codable diagnostic and procedural statements (in physician office documentation)
Understand the Ambulatory Coding Guidelines for ICD-10-CM
Evaluation and Management Coding - 20 req. hrs
Understand documentation guidelines
Define evaluation and management services
Understand terms commonly used in reporting E/M Services
Define the levels of E/M Services
Understand modifiers
Define the various E/M categories
Identify the HCPCS codes used in evaluation and management coding
Anesthesia Coding - 20 req. hrs
Describe the format and arrangement of codes in the anesthesia section
Explain the anesthesia package
Identify and apply the modifiers commonly used in reporting anesthesia services
Identify codes used in reporting qualifying circumstances
Perform the steps used in coding anesthesia services
Calculate fees for anesthesia services
Surgery Coding - 20 req. hrs
Identify coding used in the surgery section
Explain the use of modifiers used in surgery coding
Assign codes used in all surgery sections
Radiology - 20 req. hrs
Describe the Radiology surgery section format and arrangement
Identify and apply the modifiers used in Radiology coding
Pathology and Laboratory - 20 req. hrs
Describe the pathology and laboratory section structure and content
Understand the Clinical laboratory Improvement Amendments of 1988 (CLIA)
Interpret quantitative and qualitative studies
Understand the Guidelines Pertaining to Pathology and Laboratory subsections
Identify and apply the modifiers used in Pathology and Laboratory coding
Medicine Coding - 20 req. hrs
Understand the Medicine section content and code structure for all specialties
Identify and assign the appropriate modifiers used in coding Medicine services
Identify and assign the appropriate HCPCS codes used in coding Medicine services
HCPCS Level II Coding - 20 req. hrs
Understand the HCPCS code assignment hierarchy and the steps in HCPCS code assignment
Understand the effect of HIPAA on HCPCS
Identify the Level II codes that are inappropriate for professional billing
Modifiers - 20 req. hrs
Understand the types of Modifiers
Identify and assign modifiers
Reimbursement Process - 20 req. hrs
Understand the reimbursement process and mechanisms
Describe Fee Schedule management
Identify sources of coding and reimbursement guidelines
Identify payer-specific guidelines
Understand how to submit claims and the claims process
Identify the data elements of a computerized internal Fee Schedule
Coding and Reimbursement Reports and Databases - 16 req. hrs
Perform data evaluation
Interpret computerized internal Fee Schedule Reports
Analyze Payer Remittance Reports

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