As a Registered Nurse with 5 years of experience in clinical documentation and coding, I have worked extensively with ICD-10, CPT, and HCPCS coding systems. My role involved auditing medical records to ensure accuracy, compliance, and optimal reimbursement. I collaborated with healthcare providers to clarify documentation discrepancies and provided education on coding best practices. My nursing background allows me to understand clinical scenarios deeply, ensuring codes reflect the true patient condition and care provided.

I stay current by subscribing to industry newsletters like AAPC and AHIMA updates, attending webinars, and participating in continuing education courses. I also review CMS and OIG bulletins regularly to ensure compliance with federal regulations. Networking with peers in coding forums and attending annual conferences helps me stay informed about emerging trends. This proactive approach ensures my audits align with the latest standards, minimizing compliance risks for the organization.

During an audit, I discovered a recurring undercoding issue for chronic conditions, leading to revenue loss. I analyzed the root cause, which was unclear provider documentation. I organized a training session for clinicians on specificity in documentation and worked with coders to correct historical claims. This intervention improved accuracy by 20% and increased reimbursement. My approach combined education, collaboration, and corrective action to resolve systemic issues.

I approach disagreements diplomatically, using evidence-based guidelines to support my findings. For example, I present relevant coding rules and clinical documentation to facilitate a constructive discussion. If consensus isn’t reached, I escalate to a coding committee or supervisor while maintaining professionalism. My goal is to ensure accuracy without straining relationships, emphasizing shared objectives like compliance and patient care quality.

I am skilled in using EHR systems like Epic and Cerner, as well as coding-specific tools such as 3M Encoder and Optum360. I leverage data analytics platforms like Excel and Power BI to identify trends in coding errors. These tools help me conduct efficient audits, generate reports, and provide actionable insights to improve documentation and coding practices across the organization.