I have extensive experience with medical coding, having worked with ICD-10, CPT, and HCPCS codes for over five years. I am well-versed in the documentation standards set by organizations such as AHIMA and AAPC, ensuring that all medical records I audit comply with these guidelines. My background includes auditing both inpatient and outpatient records, identifying discrepancies, and recommending improvements to enhance documentation accuracy.

I ensure accuracy and compliance by meticulously reviewing each document against established coding and documentation standards. I utilize advanced auditing software to cross-reference codes and documentation with medical necessity. Additionally, I maintain up-to-date knowledge of regulatory changes and best practices through continuous education and professional development courses.

I employ a collaborative approach when communicating audit findings, focusing on education and improvement rather than criticism. I prepare detailed reports that highlight areas of non-compliance and provide actionable recommendations. I also offer one-on-one consultations to explain findings and discuss how providers can enhance their documentation practices to meet standards.

I approach conflicts with an open mind and a willingness to listen. I provide clear, evidence-based explanations for my findings and encourage dialogue to understand the provider's perspective. If disagreements persist, I escalate the issue to a higher authority while ensuring that the process remains respectful and professional, aiming for a resolution that benefits patient care and compliance.

In a previous role, I encountered a case where a series of outpatient procedures were coded inconsistently across multiple records. I conducted a thorough review, cross-referenced with clinical notes, and identified a pattern of incorrect coding. I worked closely with the coding team to correct the errors and provided training to prevent future occurrences, resulting in improved coding accuracy and reduced claim denials.