Medical Records Urgent Care
Resume:
Sarah Norva- Bacay, CPC, CEMA
Yokota Airbase, Fussa, Tokyo
*****.*****@*****.***
Objective
To obtain a coding position, applying my 22 years coding skills in Evaluation and Management, Interventional Radiology, General Surgery, Orthopedic Surgery, OB/NUR, Anesthesia, Urology, Radiology, Dental Procedures, Laboratory Clinic, Emergency Room Dept, Trauma Critical Care Unit, Ambulatory Unit, Outpatient Clinics, Urgent Care, Behavoiral/Mental facility, and Inpatient.
Professional
American Academy of Professional Coders, CPC November 2006 -present
(Certified Evaluation and Management Auditor) CEMA September 2022-present
Outpatient Coder/Trainer/Auditor (Contractor) May 2021 -present
374 MDSS/SGSR, Yokota Air Base Fussa, Japan
-Responsible for coding, outpatient/or inpatient medical records for the purpose of data quality, accurate reimbursement, severity of illness/risk of mortality assignment (SOI/ROM), and research and compliance with DHA and MHS regulations and guidelines.
-Interacts with the medical staff on issues requiring further clarification using physician query process when there are identifiable clinical indicators, conflicting documentation, or uncertainty in the documentation in the medical record. Acts as a source of reference to providers, clinical staff that have questions, issues, or concerns related in coding and billing. In ICD10-CM, CPT Professional Edition, HCPCS, Modifiers, and CDM (Chargemaster Description Master), E&M Coding updates.
-Currently serves as MHS Genesis(Cerner) Peer Expert/Super User, Proctoring/Facilitating, Informatic Committee Team, as a subject matter in coding related and revenue issues transitioning to the new system.
- Perform assessments and examine record documentation to identify inconsistencies, ambiguities, or discrepancies in inaccurate coding and documentations. Provides clarity and understanding on audit report review. Audits reflectively for accuracy of diagnosis, evaluation and management, procedure codes and documentation. Analyzes the patient medical records to identify down and up coded services in accordance with Military Health System (MHS) coding regulations and guidelines in compliance to DHA (Department Health Agency) protocol and to maximally capture all Relative Value Units (RVUs)
-Conducts ProStaff trainings to providers and clinical/technical staff in person to discuss audit review results and do a plan of action to assist and enforce proper coding practices. Updates/recommends changes to the overlays based on revisions/deletions of codes and practices or in any scope of clinic practices per Defense Health Agency (DHA) regulations and Military Health System (MHS) Guidelines.
-Proactive in monitoring and managing the Discharged Not Final Bill (DFNB) inventory. Helps with all functions of the facilities revenue cycle coding to maximize cash flow, In conjunction with Edit Failure Reporting to have a clean claim rate, and claim edit trending, to provide on the health of the accounts along trended data on root cause issues negatively impacting expected reimbursement in Revenue Integrity to improve compliance, optimize reimbursement, and mitigate denials.
Medical Certified Coder
San Joaquin General Hospital, French Camp, CA July 2008-May 2021
-Assign ICD-10, CPT, HCPCS, Modifiers, and CDM (chargemaster description master) codes in Cerner’s Power Works Practice Management system by abstracting documented information from the patient’s encounter EHR.
-Completes detailed analysis of medical records for chart content and documentation requirements.
-Assigns appropriate Evaluation & Management level codes in accordance with the National and Facility guidelines for both the professional and facility service fees.
-Completes abstracting functions of Inpatient, Outpatient, Emergency, Trauma Critical Care, and non-FHQC Clinics and Ancillary encounters.
-Enters coded medical records data in EHR, selects diagnosis and procedure codes from 3M Encoder and designated abstracting system.
-Reviews medical records, verifies coding, Medicare Severity Diagnosis-Related Groups (MS-DRG) and modifier assignments in response to insurance requests.
-Maintains a working knowledge of current guidelines and regulations affecting code assignments through continuing education sessions and approved references.
-As a Super User- provides additional hands-on experience, training new coders, onsite coders, remote coders to go through the transformation in Cerner System.
Medical Coder Certified
MEDEX Practice Solutions, Inc., Oakdale CA March 2008- June 2008
-Reviews medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD 9-CM and CPT-4 coding conventions. Sequences the diagnoses and procedures using coding guidelines. Checks medical reports for accuracy and completion. Verifies medical data in computers, clarifying information and diagnoses by communicating with healthcare providers. Utilizes computers to analyze data.
-Receives medical reports and codes a variety of Interventional Radiology, Orthopedic Surgery, Anesthesia, Urology, Obstetrics, Intensive Care, Hospital visits, Colorectal Surgery, and Dental reports.
-Assists with special projects as required.
Medical Coding Specialist
Big Valley Commercial, Modesto CA July 2006- July2007
-Reviews medical record documentation and codes disease and injury diagnoses, acuity of care, and procedures in the wide range of Outpatient and Inpatient surgeries using the current version of the classification system required, such as ICD-9-CM, CPT-4, and HCPCS coding system.
-Ensures completeness and conformance of medical records to the hospital regulations and coding conventions Medicare Severity Diagnosis Related Groups (MS-DRGs)
-Analyzes medical records to identify all pertinent procedures for proper coding, and to evaluate the adequacy of the documentation for the full scope of coding and abstracting, including inpatient discharges, surgical cases, diagnostic procedures, outpatient encounters and inpatient professional fees.
Medical Support Assistant GS/0679/04
U.S. Naval Hospital, Yokosuka, Japan January 2004 - June 2006
-Independently codes a wide variety of medical diagnostic and surgical procedures in Ambulatory Procedure Unit (APU) from patient medical records and charts, utilizing ICD-9, CM, CPT, HCPCS Level II, and Anesthesia Coding systems, in accordance with Department of Defense (DOD) coding guidelines.
-Ensures that abstract profiles are consistent with guidelines outlined by JCAHO, and other regional and local policies.
-Compliance with HIPAA policies and procedures to ensure patient confidentiality.
-Knowledge of Composite Health Care System (CHCS).
-Trains and instructs new nurses, hospital Corp-men, American Red Cross volunteers, and other staff on hospital APU protocol, policies, and procedures.
U.S. Naval Hospital, Yokosuka Japan
Third Party Claims October 2003- June 2004
-Codes all Third Party/OHI patient visits using current ICD-9 and CPT4 codes.
-Verifies all clinic/department insurance claims are coded correctly prior to submission to insure correct hospital reimbursement.
Leadership/Volunteer Work/Community Involvement
-Parish Council Officer (Secretary) for St Michael Parish/Friendship Chapel Yokota Airbase 2022-2023
-Catechist for Confirmation Class September 2021- present, Yokota Air Base Fussa Japan
-Lector, Extraordinary Minister, Choir member, Carmelite Food Donation Coordinator September 2021- present
-CWOC (Catholic Womens of Church) Evening Bible Class and Reading Program for kids - present
-DHA Coding Compliance Committee (Representative) – present
-Involve as a Benefactor for the Knight of Columbus and Rotary Club project – present
-Providing Financial Support in food donation to the monastery, and established school feeding program in the Philippines to deprived children in several towns -present
-Treasurer for American Academy of Professional Coders (AAPC) Modesto Chapter 2019
-Secretary for American Academy of Professional Coders (AAPC) Modesto Chapter 2012
-Proctoring for AAPC exams 2015 and 2019
-Coordinator in a variety of Ministries for St Joseph Parish, Oakdale, CA from 2007 –2013
-Sunday School/Catholic Confraternity of Doctrine (CCD) Teacher, Chapel of Hope, Sacred Heart Community, Yokosuka, Japan 2004-2006
-United Through Reading (UTR) Program Coordinator, Yokosuka, Japan 2004-2006
Awards
Letter of Appreciation from the Commanding Officer January 2004-June 2006 USNH, Yokosuka, Japan
Letter of Commendation July 2004- September 2004, USNH APU (Ambulatory Procedure Unit), Yokosuka, Japan
EDUCATION
Brevard Community College, Brevard, Fl 2003
Medical Coding Program
References Upon Request
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