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Reviewing Of Medical Records Discussion

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Instructions:

As a medical coder you will be responsible for reviewing patient documentation for encounters that has been added to an Electronic Health Record by a provider. You will ensure the accuracy and integrity of the codes that are used. Additionally, you will review each medical record for compliance purposes and report issues that may be apparent. When there is a question, you will ask or query your provider to confirm that the medical record supports the code selection. It really begins with the medical coder as they are the gatekeepers or coding accuracy and compliance

Include the following aspects in the assignment:

· Describe what you feel a day may be like once you become a coder

· What do you think will be most challenging?

· Summarize why it is essential to collaborate with clinical staff (MDs/APRNs) to resolve coding questions/discrepancies

· Provide an example of a time when it may be necessary to query a physician.

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