Position Overview
The Lab & Path Denial Coder is responsible for reviewing, analyzing, and resolving claim denials related to laboratory and pathology services. This role ensures accurate coding, supports denial prevention, and works closely with billing, QA, and provider teams to improve reimbursement outcomes.
Key Responsibilities
1. Denial Review & Resolution
- Analyze payer denial codes for Lab & Pathology claims.
- Identify root causes such as coding errors, missing documentation, medical necessity issues, or payer-specific rules.
- Correct CPT, HCPCS, ICD‑10, and modifier usage as required.
- Prepare and submit corrected claims or appeals with supporting documentation.
2. Coding Accuracy
- Assign accurate CPT/HCPCS codes for:
- Clinical laboratory tests
- Anatomic pathology
- Molecular pathology
- Cytopathology
- Microbiology
- Ensure compliance with NCCI edits, LCD/NCD guidelines, and payer policies.
3. Documentation Review
- Validate that provider documentation supports billed services.
- Request additional documentation when needed.
- Identify documentation gaps and communicate trends to leadership.
4. Payer Policy Knowledge
- Stay updated on Medicare, Medicaid, and commercial payer rules for Lab & Path services.
- Understand frequency limitations, bundling rules, and medical necessity requirements.
5. Collaboration & Reporting
- Work with billing, AR, QA, and coding teams to reduce recurring denials.
- Provide feedback on denial trends and coding improvement opportunities.
- Maintain productivity and quality benchmarks.
Required Skills & Qualifications
- 2–4 years of experience in Lab/Pathology coding or denial management.
- Strong knowledge of CPT (80000 series), ICD‑10‑CM, and HCPCS Level II.
- Familiarity with:
- Molecular pathology codes (e.g., 81162, 812xx series)
- Surgical pathology (88300–88309)
- Cytology (88104–88175)
- Experience with payer denial codes and appeal processes.
- Certification preferred: CPC, COC, CIC, or equivalent.
- Strong analytical and communication skills.
Performance Expectations
- Meet daily/weekly denial resolution targets.
- Maintain coding accuracy of 95%+.
- Reduce repeat denials through root‑cause identification.
- Ensure timely submission of corrected claims and appeals.
