16+ years assigning codes, auditing medical records, and providing feedback to providers, practitioners, and clinical staff in a variety of specialties (e.g. General and Orthopedic Surgery, ER, Pediatrics, OB/GYN, Internal Medicine, and Family Practice, mental health) that utilize ICD, E&M, CPT, and HCPCS Level II codes.

Extensive experience in reviews and audits of medical records for appropriate supporting documentation for ICD-10, PCS, HCPCS, CPT, and E&M codes. Demonstrates the ability to review clinical documentation and assign medical codes for multiple specialties, as well as analyze physician documentation and conduct Evaluation and Management audits.  Performs audits of medical records for coding accuracy, coding specificity, sequencing of codes, and documentation deficiencies (CDI).

As Certified Coding Specialist (CCS) and Certified Professional Coder (CPC), we possess advanced knowledge of the International Classification of Diseases, Clinical Modification (ICD-CM); Healthcare Common Procedure Coding System (HCPCS); and Current Procedural Terminology (CPT).  Our team possesses advanced knowledge and understanding of industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; and disease processes.  Also has practical knowledge of reimbursement systems, including Prospective Payment System (PPS); Ambulatory Payment Classifications (APCs); and Resource-Based Relative Value Scale (RBRVS). 

Knowledge of and proficiency in the use of EMR and numerous medical coding systems and software, as well as proficiency in the use of AHLTA, CHCS, CCE, and Essentris for compliance and data quality.  Demonstrated ability to utilize medical software programs to abstract, analyze, and/or evaluate clinical documentation, and advanced proficiency with Microsoft suite (Word, Excel, Access, PowerPoint, and Outlook).

Excellent written and oral communication skills; ability to build rapport and effectively interact with providers and healthcare staff, and collaborates closely with physicians, coding managers, clinical staff, and nurses.  Clearly and effectively express instructions, training plans, feedback, and evaluations to individuals or groups.

Extensive knowledge for understanding and applying the official coding clinic guidelines.  Knowledge of medical terminology and usage, including general medical, surgical, pharmaceutical, hospital terms, and abbreviations and abstracting techniques.  Knowledge of a broad range of references such as the ICD-10, CPT, PCS, HCPCS, medical dictionaries, manuals relating to coding textbooks, and glossaries.

More than 6 years of direct management with providing education to coding staff, billers, physicians, and other healthcare groups. Experienced Allied Health Instructor (teaching medical terminology), Billing and Coding Instructor (developing medical coding curriculum), and a Certified Professional Coding Instructor (CPC-I); utilizing a variety of teaching methods and strategies to meet the need of varying students learning styles. Routinely provides educational feedback and training to Physicians in a One-on-One and group setting.  Also provides guidance to professional/technical staff and advises providers on ways to strengthen clinical documentation skills and serves as a reliable source of reference to medical staff having questions, issues, or concerns relating to coding.