Charge Entry Specialist

Job Summary:
The Charge Entry Specialist will evaluate medical records and charge tickets to ensure completeness,
accuracy, and compliance with the International Classification of Diseases Manual – Clinical Modification
(ICD-10-CM), and the American Medical Association’s Current Procedural Terminology Manual (CPT).
The Specialist will also provide technical guidance and training on medical coding to physicians and staff.
Supervisory Responsibilities:
? None.
Duties/Responsibilities:
? Evaluates medical record documentation and charge-ticket coding to optimize reimbursement
by ensuring that diagnostic and procedural codes and other documentation accurately reflects
and supports patient visits and to ensure that data complies with legal standards and guidelines.
? Interprets medical information such as diseases or symptoms and diagnostic descriptions and
procedures to accurately assign and sequence the correct ICD-10-CM and CPT codes.
? Reviews state and federal Medicare reimbursement claims for completeness and accuracy
before submission to minimize claim denial.
? Evaluates records and prepares reports on such topics as the number of denied claims or
documentation or coding issues for review by management and/or professional evaluation
committees.
? Makes recommendations for changes in policies and procedures; works with data processing
staff to revise the computer master file. Develops and updates procedures manuals to maintain
standards for correct coding, to minimize the risk of fraud and abuse, and to optimize revenue
recovery.
? Provides technical guidance to physicians and other staff in identifying and resolving issues or
errors such as incomplete or missing records and documentation, ambiguous or nonspecific
documentation, and/or codes that do not conform to approved coding principles/guidelines.
? Reads bulletins, newsletters, and periodicals and attends workshops to stay abreast of issues,
trends, and changes in laws and regulations governing medical record coding and
documentation.
? Educates and advises staff on proper code selection, documentation, procedures, and
requirements.
? Identifies training needs, prepares training materials, and conducts training for physicians and
support staff to improve skills in the collection and coding of quality health data.
Required Skills/Abilities:
? Knowledge of ICD-10 and CPT coding guidelines; medical terminology; anatomy and physiology;
state and federal Medicare reimbursement guidelines; English grammar and usage.
? Ability to research and analyze data, draw conclusions, and resolve issues; read, interpret, and
apply policies, procedures, laws, and regulations.

? Ability to read and interpret medical procedures and terminology.
? Ability to develop training materials, make group presentations, and to train staff
? Ability to exercise independent judgment;
? Excellent written and verbal communication skills to prepare reports and related documents and
to maintain working relationships with physicians and other staff.
? Ability to maintain confidentiality.
Education and Experience:
? Possession of an Accredited Record Technician’s certification (ART) or Certified Coding Specialist
designation (CCS) issued by the American Health Information Management Association; or
? Two years of experience in medical record coding, or the
? Equivalent combination of experience, education, and training that would provide the required
knowledge and abilities.