Obligation of a CPC as defined by our certification

[michelledopson]

I have a dual position in the practice I work for and I am a CPC. I work as a part-time coder and part-time AR specialist working claim denials. Recently it has been decided the PAs & NPs in our practice will begin doing their own coding and claim submission with no coder involvement. I will be responsible for working any denials that come back for these claims in my AR specialist role. My question is: As an AR specialist with a CPC, do I have the obligation as a CPC to not only review a denied claim for the denial reason but to also review the claim in entirety to make sure the documentation supports all of the billing before submitting a corrected claim or appeal?

I appreciate any clarification and feedback this community can provide. While I have worked AR for decades, I did not receive my CPC until late 2024 and have not previously experienced this scenario.

 

[sls314]

I have a dual position in the practice I work for and I am a CPC. I work as a part-time coder and part-time AR specialist working claim denials. Recently it has been decided the PAs & NPs in our practice will begin doing their own coding and claim submission with no coder involvement. I will be responsible for working any denials that come back for these claims in my AR specialist role. My question is: As an AR specialist with a CPC, do I have the obligation as a CPC to not only review a denied claim for the denial reason but to also review the claim in entirety to make sure the documentation supports all of the billing before submitting a corrected claim or appeal?

I appreciate any clarification and feedback this community can provide. While I have worked AR for decades, I did not receive my CPC until late 2024 and have not previously experienced this scenario.

If the denial is for medical necessity or a coding error, I don't see how you could submit a corrected claim or appeal without reviewing the documentation. Those things really go hand in hand.

That said, I don't think every denial necessarily requires a full coding/documentation review. For example, if the denial is related to member eligibility, benefits, a timely filing issue, or another administrative issue, there may not be a reason to spend much (or any) time reviewing the clinical documentation.

I think the bigger question is what your employer expects of you in the AR role.

Being a CPC certainly gives you the knowledge to identify coding/documentation issues, but I don't know that the CPC credential itself creates an obligation to perform a complete coding audit on every claim you touch when you're working denials.

However, if you're being asked to submit corrected claims or appeals based on coding/documentation issues, I would expect you to review the documentation sufficiently to make sure what you're submitting is actually supported.

How else would you know what needs to be corrected or what you have grounds to appeal?