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.

• 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, athena
  
  IDX, Cerner, Next Gen) configuration, charge router rules, claim scrubber edits, and fee schedule updates.

• 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.

• 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.

• 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.

• 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 &…