Subject Matter Expert (SME) – Billing

The Billing Subject Matter Expert (SME) serves as the go-to resource for complex, specialty-specific billing across

Orthopedics, General Surgery, Plastic Surgery, Vascular, Otolaryngology (ENT), and Ophthalmology . This role ensures accurate coding, compliant charge capture, clean claim submission, and timely resolution of denials. The SME partners with clinical, front office, surgery scheduling, ASC/HOPD, and finance teams to optimize reimbursement, minimize rework, and maintain regulatory compliance. Key Responsibilities Cross‑Specialty (Core) Responsibilities Expert Escalation Point:

Lead resolution of complex coding, billing, and payer policy questions; guide staff on edits, bundling, and medical necessity. Charge Review & Edits:

Monitor WQs for CCI/NCCI edits, MUEs, and payer-specific rules; correct and educate to prevent recurrence. Denials Management:

Trend denials (CO-16, CO-97, CO-50, MUE, bundling, global conflicts, missing auth); implement corrective workflows and write appeal letters with supporting guidance. Authorization & Eligibility:

Oversee pre-cert workflows for surgeries, injections, imaging, DME, drugs (buy-and-bill); ensure benefits and financial clearance (ABN/Good Faith Estimate when applicable). Documentation Integrity:

Align clinical documentation with CPT/HCPCS and ICD-10-CM; drive provider education on specificity, laterality, time-based services, split/shared, and global periods. Regulatory Compliance:

Maintain adherence to Medicare/Medicaid, commercial payer policies, OIG guidance, LCD/NCD coverage criteria, and modifier usage. Training & SOPs:

Create job aids, quick-reference guides, and deliver staff/provider training for updates (CPT/ICD changes, payer policy changes). Data & Process Improvement:

Analyze KPIs (DNFB, first-pass yield, days to payment, denial rate by reason, AR > 90, write-offs, net collection rate) and lead improvement initiatives. Systems Optimization:

Partner with IT for EHR/PB (e.g., Epic, athenaIDX, Cerner, NextGen) configuration, charge router rules, claim scrubber edits, and fee schedule updates. Specialty-Specific Expertise

Orthopedics Global Surgical Package:

Apply fracture care global rules (casting/splinting included/excluded), post-op modifiers

-58/-78/-79 , staged/related procedures, return to OR. Injections & Imaging:

Bill joint injections (e.g., 20610/20611) with

ultrasound guidance (76942)

when documented; understand MUEs and bilateral/laterality modifiers ( RT/LT, -50 ). DMEPOS:

Manage braces/splints (L-codes/A-codes), proof of delivery, and CMNs where required. Implants & Facility Coordination:

Coordinate ASC/HOPD authorizations, implants, device credits, and carve-outs. General Surgery

Endoscopy & Procedures:

Distinguish screening vs diagnostic colonoscopy (modifiers

33, PT

as applicable); apply bundling/edit logic for laparoscopic vs open procedures. Hernia & Soft Tissue:

Know payer-specific documentation for hernia types, mesh use, re-do surgery, and post-op complications. Trauma & Assistant Surgeons:

Apply assistant surgeon modifiers ( -80/-81/-82 ), trauma activation when relevant, and global rules on staged operations. Plastic Surgery (Reconstructive & Cosmetic)

Medical Necessity & Photos:

Manage

reconstructive vs cosmetic

determinations, pre-auths with photo documentation, and payer medical policies. Complex Repairs & Flaps:

Code layered closures, tissue rearrangements, flaps/grafts, breast reconstruction (timing and laterality). Financial Consents:

Enforce self-pay estimates, ABNs/financial waivers for non-covered cosmetic services, and dual billing (cosmetic + medical when appropriate). Allergy Services:

Bill allergy testing ( 95004/95024 ), serum prep ( 95165 ), and immunotherapy administration ( 95115/95117 ) per payer guidelines. Audiology & Vestibular:

Understand diagnostics (e.g.,

92557, 92567, 92540 ), medical necessity, and supervision requirements. Sinus/Otologic Procedures:

Apply endoscopic sinus surgery coding, septoplasty, tympanostomy tube policies, and procedure bundling rules. Ophthalmology

E/M vs Eye Codes:

Apply ophthalmic exam codes ( 92002–92014 ) vs E/M based on payer; understand incident-to and time/documentation requirements. Imaging & Testing:

Bill

OCT (92133/92134), visual fields (92083), fundus photos (92250)

with LCD-driven indications and frequency limits. Drugs & Injections:

Manage

intravitreal injections (67028)

with buy-and-bill J-codes (e.g., anti-VEGF), wastage reporting (JW/JZ), units, and serial treatment auths. Qualifications

Education:

High school diploma or equivalent required; Associate’s/Bachelor’s in Healthcare Administration, HIM, Business, or related field preferred. Certifications:

CPC, COC, CPB, CCS-P, or CMOM

strongly preferred; specialty credentials (e.g.,

COSC

for orthopedics,

COA/COT

familiarity for ophthalmology) a plus. Experience:

3–5+ years

in professional billing/coding;

multi-specialty

experience required with

at least two of the target specialties . Knowledge:

Deep understanding of CPT/HCPCS, ICD-10-CM, global periods, modifiers, NCCI, MUEs, LCD/NCD, and payer medical policies (Medicare, Medicaid, commercial). Systems:

Proficiency with EHR/PM/claim scrubbers (e.g.,

Epic, athenahealth, NextGen, Cerner, eClinicalWorks, Availity, Change Healthcare ). Skills:

Advanced denial analytics, root-cause problem solving, provider education, clear written appeals, and cross-functional collaboration. Core Competencies

Regulatory & Payer Policy Mastery Detail Orientation & Audit Rigor Data Literacy (Excel/BI) & Trend Analysis Communication & Training Delivery Change Management & Process Design Professional Judgment & Confidentiality (HIPAA) Working Conditions

Office-based with potential hybrid/remote arrangement. Occasional travel to clinic sites for training or audits. Ability to meet cyclical deadlines (month-end close, payer audits, coding updates).

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