Ketan Vyas

Sr Clinical Coder (Concurrent and Prospective) @Chirok Health

Mumbai, IN

Core Responsibilities of a CDI Coder: 1. Clinical Documentation Review: • Analyze medical records for completeness, accuracy, and specificity. • Ensure documentation supports the diagnoses and procedures coded. • Identify any gaps, ambiguous terms, or inconsistencies. Querying Physicians: • Generate queries to providers to clarify missing, conflicting, or unclear documentation. • Ensure queries are compliant with official guidelines and facility policies. Collaboration with Providers and Coders: • Work closely with physicians, coders, and CDI specialists to improve documentation practices. • Educate clinical staff on documentation requirements for accurate coding. Code Validation and Assignment: • Ensure that ICD-10-CM, CPT, and PCS codes accurately reflect the patient’s diagnoses and procedures. • Validate coded data against clinical documentation. Quality Improvement: • Contribute to improved patient outcomes and better reimbursement through enhanced documentation. • Support initiatives that focus on reducing denials and improving DRG accuracy. Compliance and Audit Support: • Ensure adherence to coding and documentation regulations (e.g, CMS, AHIMA, AHA). • Assist in internal and external audits, identifying trends and opportunities for improvement. Education and Training: • Provide training and feedback to coding staff and providers about CDI best practices. • Stay updated with the latest coding and CDI guidelines.

Dy Patil College

Bpharma, Handling of Instrument