Title: Medical Coder - Long Term Acute Care Hospital
Reports to: Director of Operations
Effective Date: 12.2025 Revise Date:
Summary
The Medical Coder – Long Term Acute Care Hospital is responsible for accurate and compliant coding of diagnoses, procedures, and services for inpatient, outpatient, and skilled nursing encounters. This role supports appropriate reimbursement under Medicare, Medicaid, and commercial payers while ensuring compliance with CMS, DRG, and hospital coding regulations.
Core Responsibilities:
Assign ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes for inpatient encounters
Ensure accurate DRG/APR-DRG assignment and appropriate sequencing of diagnoses and procedures
Review operative reports, discharge summaries, progress notes, and ancillary documentation
Collaborate with CDI staff to clarify diagnoses and ensure complete, compliant documentation
General Responsibilities:
Ensure compliance with CMS, Medicare, Medicaid, and payer-specific coding guidelines
Maintain productivity and accuracy standards
Resolve coding-related denials, edits, and payer inquiries
Participate in internal and external audits and corrective action plans
Stay current with annual code updates and regulatory changes
Maintain HIPAA compliance and patient confidentiality
Minimum Qualifications:
High school diploma or equivalent required; associate or bachelor’s degree in Health Information Management or related field preferred
Minimum of 2–5 years of medical coding experience in hospital and/or skilled nursing settings
Demonstrated knowledge of Long Term Acute Care Hospital.
Required: CPC, CCS, or CCS-P
Preferred: RHIT or RHIA
Hospital inpatient specialty certification a plus
Strong understanding of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS
Knowledge of DRG/APC-Assignment, and clinical terminology
Proficiency with EHR systems and encoder software
High attention to detail and strong analytical skill
Create and send compliant queries to physicians to clarify documentation for coding