MRT- Inpatient Coder

Summary

The Medical Records Technician (MRT) Coder is responsible for performing a quality review of patient care documents and assigning codes specific to the type of care provided. For this assignment, Inpatient MRTs (Coders) select and assign codes from current versions of ICD-CM, PCS, and/or CPT and HCPCS classification systems for the full scope of inpatient facility and/or professional services.

Duties

The duties below are for the GS-0675-08, Journey Level. FUNCTIONS OR SCOPES OF PRACTICE INCLUDE BUT ARE NOT LIMITED TO: Utilize various computer applications to abstract records and assign codes to documented patient care records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for: Diagnosis Complications/major complications Comorbid/major comorbid conditions Surgery And procedures for accurate assignment of diagnosis-related groups (DRG), and/or assigning PCS/HCPCS codes for inpatient facility and/or professional services. They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of inpatient settings and specialties. Has in-depth knowledge of: Medical terminology Anatomy & physiology Diseases Treatments Diagnostic tests And medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include: Current versions of the International Classification of Diseases (ICD) Procedure Coding System (PCS) And/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate: Diagnosis Operation Procedure Ancillary Evaluation and Management code to ensure ethical, accurate, and complete coding. Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Maintains current knowledge of regulatory and policy requirements affecting coded information. Independently reviews health record documentation to abstract all required: Medical Surgical Ancillary Demographic, social, and administrative data and queries clinical staff, as appropriate. Patient health records may be paper or electronic. Independently assesses: Basic documentation requirements Coding requirements Accepted nomenclature and proper sequencing to obtain correct DRG Supports medical necessity Resolves encoder edits and ensures codes accurately reflect services rendered Ensures provider documentation supports the diagnoses and procedures coded. Directly consults with clinical staff to resolve issues related to conflicting or questionable clinical documentation. Utilizes the facility computer system and software applications to: Code Abstract Record and transmit data to the national VA database in Austin Corrects any identified data errors Inconsistencies or audit findings in a timely manner to ensure acceptance in the national VA database within established timelines. Research references to resolve any questionable code errors; contacts a senior coder or supervisor when needed. Uses a variety of window-based applications in day-to-day activities and duties, such as: Outlook Excel Word and Access; Competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite Ensures current versions of all software applications are loaded and functional after any updates or changes. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Other Duties as assigned. Work Schedule: M-F 8:00 am - 4:30 pm or as determined by the supervisor. Compressed/Flexible: This may be authorized at the supervisor's discretion. Telework: This is a Remote position. Virtual: This is not a virtual position. Functional Statement #: 11975F, 11976F, 11977F, 11978F, 11979F

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected, but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC 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. Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Medical Records Technician (Coder-Inpatient): GS-4: Experience or Education: None beyond basic requirements. Assignment: Employees at this level serve as entry-level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Inpatient MRTs (Coder) select and assign codes from current versions of ICD-CM and the PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with close guidance from higher-level MRTs (Coder). They also use various computer applications to abstract records, assign 11 codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. GS-5: 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 and PCS Official Conventions and Guidelines for Coding and Reporting Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation Knowledge of The Joint Commission requirements, CMS, and