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Coding Specialist

Job Description - Coding Specialist

Description

  • Review inpatient trauma cases and assign accurate ICD-10-CM and ICD-10-PCS codes.

  • Determine the appropriate MS-DRG/APR-DRG assignment.

  • Analyze documentation from:

    • Emergency Department (ED)

    • Trauma History & Physical

    • Operative reports

    • ICU progress notes

    • Consultant notes

    • Discharge summaries


  • Identify the principal diagnosis, secondary diagnoses, principal procedure, and additional procedures.

  • Capture CC/MCC, POA indicators, complications, and comorbidities accurately.

  • Query physicians for incomplete or unclear documentation when appropriate.

  • Ensure compliance with ICD-10-CM/PCS Official Guidelines, Coding Clinic guidance, CMS regulations, and client-specific policies.

  • Meet established productivity and quality benchmarks.

  • Participate in internal audits, education, and process improvement initiatives



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