Karla Tusson, CPC, CPMA, CRC

• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, HHS Protocols and any additional applicable rule set.
• Utilize HHS’ Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC) identified from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year
• .Apply longitudinal thinking to identify all valid and appropriate data elements and opportunities for data capture, through the lens of HHS’ Risk Adjustment.
• Perform various documentation and data audits with identification of gaps and/or inaccuracies in risk adjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission program.

• Perform Retrospective & Prospective Audit Reviews of the electronic health records, ensuring that all submitted ICD 10-CM codes are fully supported by clinical documentation.
• Maintain Excel spreadsheets for tracking and reporting findings of audit reviews and clinical documentation improvement (CDI) opportunities to providers in order to maximize coding of ongoing risk adjusted conditions.
• Review year to year reporting of HCC Risk Adjusting codes for any potential GAP opportunities.
• Provide coding educational feedback to provider's from results of audit review findings.
• Perform QA on coding vendor code capture for coding accuracy.
• Perform Peer to Peer reviews of audits.
• Reconcile non-codable charge tickets returned from coding vendor.
• Perform other duties as required and assigned.

As Team Leader in the DVA/RADV/IVA department, provided training and assurance of quality audits conducted by coding team. Through leadership and mentoring skills, successfully led staff through the myriad of complex requirements involved in the CMS-mandated Initial Validation Audit (IVA). Strong ability to develop and maintain collaborative relationships and positive outcomes within processes, colleagues, and leadership.

• Validated Issuer Enrollment, Claims and Health Status data against CMS EDGE server data.
• Validate and abstract HCC diagnosis codes from provider documentation utilizing current ICD Guidelines
• Perform Quality Assurance reviews of auditor validations of Enrollment, Claims and HSV
• Provided guidance with data entry on proprietary audit platform
• Provided education and feedback to numerous clients and staff to ensure understanding of coding parameters
• Assign work assignments to auditors and ensured completion
• Maintained 95% accuracy rating

• Performed remote chart review for the purposes of HCC Risk Adjustment audits including complete code capture reviews.
• ·Reviewed medical records for completeness, accuracy, and compliance with ICD-9 & ICD-10 Coding Guidelines and CMS regulations.
• Reviewed medical records and abstracted diagnosis codes supported by provider assessment and prescribed medication.
• Assigned exception codes when recorded documentation is inadequate, ambiguous or otherwise insufficient for medical record abstraction/review.
• Maintained a 95% coding accuracy.

• Performed continuous QA’s of coding staff to identify trending errors and provided educational training and feedback
• Conducted independent quality assurance reviews on the coding staff following coding guidelines, company guidelines, and individual client guidelines, when applicable
• Provided individual feedback of the quality assurance results in a timely manner to coders
• Provided staff training and follow up in areas requiring improvement
• Provided ongoing technical training including coding and Medicare Risk Adjustment
• Maintained ongoing communication with management on targeted quality goals
• Compiled data from QA results identifying top issues to be included in quarterly coder training
• Maintained 95% accuracy rating

• Verified and ensured accuracy, completeness, specificity and appropriateness of diagnosis codes based on services rendered
• Abstract all ICD-9 diagnosis codes according to CMS HCC Coding Guidelines
• Completed appropriate paperwork and system entry of HCC codes
• Assisted client in training new hires in HCC Coding Guidelines and Procedures
• Provided documentation to client to assist in their educational feedback to providers