Job description
Description Audit inpatient trauma coding for accuracy and completeness.
Validate ICD-10-CM, ICD-10-PCS, and MS-DRG/APR-DRG assignments.
Review trauma documentation including: Emergency Department records Trauma history & physical Operative reports ICU progress notes Discharge summaries Ensure correct sequencing of diagnoses and procedures.
Verify POA (Present on Admission), CC/MCC capture, and trauma-related complications.
Identify documentation deficiencies and recommend physician queries whe…
