I have extensive experience with ICD-10-CM and CPT coding, having worked in a hospital setting for the past five years. I am proficient in accurately assigning diagnosis and procedure codes to patient records, ensuring compliance with coding guidelines and regulations. My experience includes handling complex cases and utilizing advanced coding software to maintain high accuracy and efficiency.

I ensure accuracy and compliance by thoroughly reviewing patient charts, understanding the medical procedures and diagnoses, and cross-referencing with the latest coding guidelines. I regularly update my knowledge through continuing education and stay informed about any changes in coding regulations. Additionally, I utilize auditing tools and participate in peer reviews to maintain high standards.

To manage a high volume of medical records, I prioritize tasks based on deadlines and complexity. I utilize efficient coding software that helps streamline the process and reduce errors. I also maintain good communication with the healthcare team to ensure all necessary information is available for accurate coding. Time management and organizational skills are crucial in this role.

When facing discrepancies in patient documentation, I first attempt to clarify any ambiguities by consulting with the healthcare providers. If further clarification is needed, I follow the facility's protocol for resolving documentation issues. I ensure that all coding decisions are supported by the available evidence and adhere to coding best practices.

In a previous role, I identified an incorrect procedure code that was assigned due to a misinterpretation of the physician's notes. I reviewed the documentation thoroughly, consulted with the physician, and corrected the code to accurately reflect the procedure performed. This not only ensured proper billing but also maintained the integrity of the patient's medical record.