Conduct detailed DRG validation audits on selected inpatient medical records to ensure coding accuracy, completeness, and compliance with ICD-10-CM/PCS, AHA Coding Clinic, and CMS guidelines.
Review documentation to confirm that all reported diagnoses and procedures are supported and coded to the highest level of specificity.
Validate the assignment of the discharge disposition, Present on Admission (POA) indicators, and sequencing of diagnoses.
Identify and correct discrepancies between coded data and clinical documentation.
Perform secondary reviews as needed for complex or disputed coding cases.
- Compliance and Quality Assurance
Ensure adherence to all official coding guidelines, facility policies, and payer-specific rules.
Monitor and analyze audit trends to identify coding or documentation issues impacting data quality and reimbursement.
Collaborate with the Compliance Department to address audit findings and ensure regulatory adherence.
- Education and Mentoring
Provide ongoing feedback and coaching to coders and Clinical Documentation Improvement (CDI) Specialists to enhance coding accuracy and documentation quality.
Develop and deliver targeted training sessions on DRG optimization, clinical indicators, coding guidelines, and audit findings.
Serve as a resource for complex coding questions and provide interpretation of regulatory updates and coding guideline changes.
- Reporting and Documentation
Maintain detailed and accurate records of all audit activities and findings.
Prepare periodic audit reports summarizing trends, root causes, and recommendations for improvement.
Communicate results to management and participate in performance improvement initiatives.
- Collaboration
Work closely with CDI teams, physicians, and other clinical staff to clarify documentation and ensure accurate code assignment.
Partner with IT and data analytics teams to improve coding and auditing processes.