Peter Golder

Physician-trained certified coding professional with MD, CCS, and CDIP credentials and hands-on inpatient medical coding experience performed during residency at Tidelands Health. Experienced reviewing acute-care inpatient medical records, interpreting clinical documentation, assigning ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, applying Official Coding Guidelines, supporting MS-DRG/APR-DRG accuracy, and recognizing documentation gaps affecting reimbursement, quality reporting, compliance, and data integrity. Targeted for Inpatient Coder – CCS Active with Reqroute, Inc.

Strong fit for remote inpatient coder, acute-care facility coder, hospital coder, ICD-10-CM/PCS coder, HIM coder; available for long-term remote contract work, 1099/freelance-style independent coding.

Resident Physician / Inpatient Medical Coder - Tidelands Health - Myrtle Beach / Georgetown, SC

(2025-06 - 2026-04)

Performed inpatient medical coding in addition to resident physician responsibilities, applying ICD-10-CM diagnosis coding and ICD-10-PCS procedure-coding concepts to acute-care inpatient encounters.

• Reviewed inpatient medical records, including H&P notes, progress notes, consult notes, operative/procedure reports, medication records, laboratory data, imaging results, pathology reports, and discharge summaries.
• Applied Official Coding Guidelines, UHDDS concepts, principal diagnosis selection, secondary diagnosis sequencing, POA awareness, documentation specificity, and compliance-focused coding principles.
• Evaluated documentation for MS-DRG/APR-DRG impact, CC/MCC capture, severity of illness, risk of mortality, clinical validation, comorbid conditions, complications, and procedure documentation.
• Identified ambiguous or incomplete documentation, missing specificity, conflicting diagnoses, and opportunities for provider clarification or compliant physician query workflows.
• Used physician-level knowledge of anatomy, physiology, pathophysiology, pharmacology, disease processes, clinical indicators, diagnostics, and inpatient hospital course to interpret complex records.
• Worked with Epic, Cerner, and 3M coding/encoder-related workflows to support chart review, documentation analysis, code selection, and electronic medical record navigation.
• Maintained HIPAA compliance and patient confidentiality while handling protected health information, chart documentation, coding data, and clinical records.
• Applied physician-level understanding of evaluation, management, diagnoses, procedures, documentation specificity, and medical decision-making to professional-fee coding concepts.

Doctor of Medicine - Medicine - Indiana University School of Medicine (2025-05)

Bachelor of Science - Biology - Indiana University Indianapolis (2021-05)