I have over five years of experience in clinical documentation and medical coding, working extensively with electronic health records (EHR) systems. My role involved reviewing patient charts, ensuring accuracy, and assigning appropriate ICD-10 and CPT codes. I am proficient in identifying discrepancies and collaborating with healthcare providers to clarify documentation. My attention to detail and understanding of medical terminology have consistently ensured compliance with regulatory standards and improved billing accuracy.

To ensure accuracy and compliance, I follow a systematic approach. I cross-check documentation against coding guidelines and regulatory requirements, such as HIPAA and CMS standards. I use EHR tools to flag inconsistencies and collaborate with clinicians to resolve ambiguities. Staying updated on coding changes and attending regular training sessions helps me maintain compliance. My meticulous review process minimizes errors, reduces claim denials, and ensures that documentation supports the level of care provided.

In a previous role, I identified a missing diagnosis in a patient’s chart that would have led to undercoding and revenue loss. I immediately contacted the physician to clarify the omission and updated the documentation. This correction not only ensured accurate billing but also improved the patient’s care continuity. My proactive approach prevented potential compliance issues and demonstrated my commitment to maintaining high-quality documentation standards.

When disagreements arise, I approach the situation professionally and collaboratively. I present the specific documentation issue, referencing coding guidelines or regulatory requirements to support my perspective. I listen to the provider’s reasoning and work together to find a resolution that ensures accuracy and compliance. Maintaining open communication and mutual respect helps build trust and fosters a cooperative environment, ultimately improving documentation quality.

I stay current by regularly attending webinars, workshops, and industry conferences focused on coding and documentation updates. I also subscribe to professional journals and participate in online forums to discuss emerging trends. Additionally, I leverage resources from organizations like AHIMA and AAPC. By continuously educating myself, I ensure that my knowledge remains up-to-date, enabling me to apply the latest standards and best practices in my work.