Stacey Harris

• Reviewed and coded medical records according to guidelines and regulations.
• Collaborated with healthcare professionals to clarify patient information and coding requirements.
• Utilized coding software to ensure accurate assignment of ICD-10, CPT, and HCPCS codes.

Shifting focus to MDM (number/complexity of problems, data reviewed, risk) and total time spent on the encounter.

Training to document only what is medically necessary.

Medical necessity documentation must clearly show the service was needed for diagnosis or treatment

Under coding prevention: training clinicians avoid lost revenue through accurate documentation

E/M Audit education

• Led team of representatives to ensure excellent patient care.
• Training for new staff on patient service protocols.

• Assisted patients with daily living activities and personal hygiene needs.
• Monitored patient vital signs and reported changes to nursing staff.
• Maintained cleanliness and organization of patient rooms and common areas.