I am proficient in ICD-10-CM, CPT, and HCPCS coding systems. To ensure accuracy, I meticulously review medical records, cross-reference coding guidelines, and use encoder software for validation. I also stay updated with coding updates and attend regular training sessions to maintain compliance with industry standards.

When encountering unclear documentation, I first consult the physician or healthcare provider for clarification. If immediate clarification isn’t possible, I document the issue and use coding guidelines to assign the most accurate code based on available information. I ensure all actions are compliant with organizational policies and coding ethics.

Inpatient coding focuses on assigning diagnosis and procedure codes for hospital stays, often using ICD-10-PCS for procedures. Outpatient coding, on the other hand, typically involves CPT codes for shorter visits. My experience includes coding complex inpatient cases, such as surgeries and extended hospitalizations, while ensuring compliance with DRG and reimbursement requirements.

I stay current by subscribing to coding newsletters, attending webinars, and participating in professional organizations like AHIMA or AAPC. I also review updates from CMS and other regulatory bodies regularly. This proactive approach ensures I remain compliant and knowledgeable about the latest coding standards and practices.

I adhere strictly to HIPAA regulations by accessing only the necessary patient information required for coding. I use secure systems, avoid discussing cases in public areas, and ensure all electronic and physical records are stored securely. Maintaining confidentiality is a top priority in my coding practice.