Frances Hall

Inpatient Coding/Level I

Coding of complex inpatient records to include Level I, transplant, and multiple complex surgical procedures. Analyze and interpret clinical documentation from medical records to extract data and apply ICD-10-CM and ICD-10-PCS codes for hospital reimbursement. When necessary, query providers for missing or additional documentation or clarification of diagnoses or procedures. Abstract, codes and assigns necessary demographic and clinical data elements required for inpatient records. Code using 3M 360, Epic PR

Inpatient Coding/Level I Trauma, Level II

Coding of complex inpatient records to include Trauma Level I, transplant, and multiple complex surgical procedures.
Analyze and interpret clinical documentation from medical records to extract data and apply ICD-10-CM and ICD-10-PCS codes for hospital reimbursement.
When necessary, query providers for missing or additional documentation or clarification of diagnoses or procedures.
Abstract, codes and assigns necessary demographic and clinical data elements required for inpatient records.
Code using 3M 360, Epic PR

Client: Sentara Healthcare

• Audit new inpatient coders
• Train new inpatient coders in Meditech
• Review facility policies and procedures and client coding guidelines with new coders
• Answer coding questions from coders
• Review coder queries to ensure compliance
• Review HAC (Hospital Acquired Condition) claims
• Analyze and interpret documentation from medical records and complete accurate coding of diagnoses and procedures per Coding Guidelines.
• Abstract pertinent information from medical record.
• Code using 3M and Meditech.

• Inpatient Coding
• Analyze and interpret documentation from medical records and completes accurate coding of diagnoses and procedures per Coding Guidelines
• Query providers for missing documentation or questions regarding documentation when needed
• Abstract pertinent information from medical record
• Code using 3M 360 Encompass, 3M HDM, Powerchart, Cerner CIS

• Inpatient Coding 
•  Analyze and interpret documentation from medical records and completes accurate coding of diagnoses and procedures per Coding Guidelines.
• Abstract pertinent information from medical record
• Coding using 3M encoder and Epic system.

• ICD-10-CM, ICD-10-PCS Training.
• 3M, Optum Webstrat, Quantum encoder training.
• Coding of over 300 inpatient medical records in education environment.