Outpatient Documentation Coding Accuracy Review

I have a backlog of outpatient visit records that must undergo a Clinical Documentation Integrity review with a single goal: verify the accuracy of every medical code attached to each encounter. The charts are already complete from a clinical standpoint, but before billing is finalized I want independent confirmation that every ICD-10-CM, CPT and HCPCS code aligns perfectly with the documented diagnoses, procedures and payer guidelines.

Your task XXXX XXXX open each chart, compare the narrative notes, labs, imaging and orders against the assigned codes, and flag any discrepancies or missed opportunities for greater specificity. A concise rationale must accompany every recommended change so my internal team can learn from the findings and update our templates.

Deliverables • Spreadsheet (or EMR audit log) listing each record reviewed, original codes, recommended revisions and rationale • End-of-engagement summary highlighting recurring documentation gaps and coder education points • Turnaround report confirming total charts audited and overall error rate

Acceptance criteria • 100 % of provided records reviewed • All change recommendations reference the appropriate ICD-10-CM, CPT or payer guideline paragraph • Error summary remains below a 5 % margin of oversight in your own QA check

Our EMR is cloud-based; you will receive view-only access and can export to Excel or use built-in audit tools, whichever is faster for you. I’m ready to grant access as soon as we agree on the timeline and milestones. Rate: EUR 12–18/hr Skills: Data Entry, Report Writing, Data Analysis, Healthcare Education