Medical Records Technician (Coder - Outpatient and Inpatient)

Summary

This position is in the Health Information Management (HIM) section at the Lt. Col. Luke Weathers, Jr. VA Medical Center. Medical Records Technicians (MRT) (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

Duties

These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Duties include but are not limited to the following: Diagnoses and procedures will be coded utilizing the current edition of ICD, Clinical Modification (CM), and Procedure Coding System (PCS), CPT, and/or HCPCS. Applies knowledge of health record content, medical terminology, anatomy and physiology, disease processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services. Selects and assigns code from the current version ICD, CPT, and/or HCPS. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic record. Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to national VA databases. Identify data errors are reviewed with a senior coder or the supervisor and corrections made as directed. Work Schedule: Monday - Friday; 7:30 am - 4:00 pm or 8:00 am - 4:30 PM Telework: Not Available. Remote: This position currently has a mid-term Return to Office (RTO) extension of 180 days. Please note that this extension is subject to change. Candidates may be required to return to the office if agency policy is updated or if the exemption is not extended. Must be able to travel within 50 miles of a VA Facility if remote status is cancelled. Virtual: This is not a virtual position. Functional Statement #: 51347-F, 51348-F, 51349-F, 51349-5, 000000 Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.

Qualifications

Basic Requirements: English Language Proficiency - MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience and Education - Experience - One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR, Education - Please see education below for details; OR, Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, Experience/Education Combination - Please see information below under education. Certification - Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Grade Determinations: GS-4 MRT (Coder - Outpatient and Inpatient) - Experience or Education Requirement: None beyond basic requirements. GS-5 MRT (Coder - Outpatient and Inpatient) - Experience: In addition to meeting the basic requirements, to qualify for the GS-5 you must meet one of the following experience or education requirements: Experience: One year of creditable experience equivalent to the next lower grade level; OR Education: Successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education, with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in health information management or technology. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.). Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6 MRT (Coder - Outpatient and Inpatient) - Experience- One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. Comprehensive knowledge of current classification systems, such as ICD, CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. GS-7 MRT (Coder - Outpatient and Inpatient) - Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or pro