Medical coding compliance consists of providing analysis, auditing, investigation, recommendations, research, and other support to ensure observance or conformity with official coding policies, regulations, requirements, and standards. Revenue integrity consists of providing analysis, auditing, investigation, recommendations, research, and other support to prevent or recapture lost revenue from healthcare operations.
Advanced knowledge of the International Classification of Diseases, Clinical Modification (ICD-CM), and Procedural Coding System (PCS); Healthcare Common Procedure Coding System (HCPCS); and Current Procedural Terminology (CPT).
Advanced knowledge of reimbursement systems, including Prospective Payment System (PPS) and Diagnostic Related Groupings (DRGs); Ambulatory Payment Classifications (APCs); and Resource-Based Relative Value Scale (RBRVS).
Advanced knowledge and understanding of industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; and disease processes.
Practical knowledge of medical specialties; medical diagnostic and therapeutic procedures; ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology); and revenue cycle management.).
Thorough understanding of Government rules and regulations regarding medical coding, reimbursement guidelines, and healthcare fraud; commercial reimbursement guidelines and policies; coding audit principles and concepts, and potential areas of risk for fraud and abuse.
Advanced knowledge of revenue cycle management, project management concepts, business analysis, training methods, clinical documentation improvement, and continuous process improvement processes.
A minimum of ten years of medical coding and/or auditing experience in two or more medical, surgical, and ancillary specialties within the past 15 years, including at least 5 years of experience in a training role (training auditors, coders, and/or providers), OR
A minimum of three years’ training experience within the last six years in a military coding environment. A minimum of one (1) year of performance in the specialty is required to be qualifying. Training expertise must include identifying coding training opportunities; developing training plans and material, and instruction/delivery of the training to medical coder and clinical audiences. Multiple specialties encompass different medical specialties (i.e. Family Practice, Pediatrics, Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes. Ancillary specialties (PT/OT, Radiology, Lab, Nutrition, etc.) that usually do NOT use E&M codes do not count as qualifying experience.
Coding, auditing and training exclusively for specialties such as home health, skilled nursing facilities, and rehabilitation care will not be considered as qualifying experience. Coding experience limited to making codes conform to specific payer requirements for the business office (insurance billing, accounts receivable) is not a qualifying factor.
Education: A minimum of one of the following:
An associate’s degree in Health Information Management;
A university certificate in medical coding;
At least 30 semester hours’ university/college credit that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology.
Education in section must be from an accredited educational institution recognized by the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC).
Completion of AAPC or AHIMA coding exam preparation courses that include the above coursework and lead to successful course completion and coding certification may be accepted in lieu of university/college credit by the AFMS MCPO on a case-by-case basis.