Certified Coding Specialist

What you’ll do:

The Certified Coding Specialist is responsible for accurate and compliant coding of complex orthopedic procedures across all care settings. This role directly impacts revenue integrity by ensuring optimal CPT/ICD-10 coding, minimizing denials, and supporting provider’s documentation improvement.

Responsibilities/Duties:

Complex Surgical Coding

- Code high-complexity orthopedic and neurosurgical procedures

- Verifying all documentation is complete and compliant

- Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines.

- Follows coding conventions and ensure accurate assignment of:

- CPT (including add-on codes, modifiers, bundling rules)

- ICD-10 diagnoses supporting medical necessity

- Validate:

- Levels, laterality, approach (anterior/posterior)

- Instrumentation and graft usage

- Identify missed billable components (e.g., additional levels, hardware, biologics)

- Query provider for any necessary clarification related to unclear, unspecified or missing/incomplete documentation

- Apply payer-specific coding rules and edits

Denial Prevention & Root Cause Ownership

- Researches, analyzes, recommends, and facilitates a plan of action to correct discrepancies and prevent future coding errors:

- Review coding-related denials (medical necessity, bundling, documentation)

- Perform root cause analysis and trend identification

- Partner with RCM and vendor teams to implement corrective actions

- Develop coding edits and pre-bill review processes for high-risk procedures

Pre-Bill Quality Review

- Perform targeted pre-bill audits for:

- High-dollar orthopedic surgeries

- Multi-level and complex cases

- Ensure documentation supports:

- Medical necessity

- Procedure specificity

- Escalate documentation gaps prior to claim submission

Provider Documentation Improvement

- Partner with surgeons to improve documentation quality

- Provide targeted, case-based feedback:

- Missing elements impacting coding accuracy

- Opportunities to fully capture procedure complexity

- Support education on:

- Modifier usage

- Documentation specificity (levels, implants, approach)

Vendor Oversight & Coding Quality Control

- Audit external coding vendor performance (if applicable)

- Identify discrepancies between internal and vendor coding

- Provide feedback and enforce coding standards

- Support development of SOPs and coding guidelines

- Serves as primary resource and Spire Point of Contact (SPOC) between provider and vendor

Appeals

- Support appeals for coding-related denials

- Provide clinical/coding rationale and documentation validation

- Partner with AR teams on high-value accounts