The Medical Record Technician/Coder is a staff position located under the Health Information Management Section of the Medical Administration Service. This position is responsible for maintaining the quality of patient records, assigning of appropriate International Classification of Diseases Clinical Modification (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and various other duties as assigned.
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. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience or 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: An associate'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 technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records). 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: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). 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. 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-Outpatient), GS-04: Experience or Education: None beyond basic requirements. Medical Records Technician (Coder-Outpatient), GS-05: 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 (KSAs): 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. Medical Records Technician (Coder-Outpatient), GS-06: Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities (KSAs): 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 ICDCM, 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. Medical Records Technician (Coder-Outpatient), GS-07: Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities (KSAs): 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 procedures, and the relationship between health record documentation and code assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.
Duties May Include But Are Not Limited To: Timely, accurate and complete capture of required abstracted data from each inpatient and ambulatory care episode of treatment; Code all inpatient stays (facility and professional fees), all write-in diagnoses and procedures for outpatient encounters and laboratory, radiology, surgical and outpatient encounters that are billed to insurance companies; Manually code from the medical record documentation and enter into the appropriate software packages; Timely and accurate coding purpose of visit (diagnoses) including identifying the primary and secondary diagnoses to the most specific code available, services provided (procedures and/or Evaluation and Management level of care), practitioner, and other case mix data for all ambulatory and inpatient encounters; Maintains a control system to ensure comprehensive submission of all codes for the care provided into the Patient Care Encounter (PCE), Automated Information Capture System (AICS), Patient Treatment File (PTF), Appointment Management, Surgery Package and other applicable programs in VISTA; Use of judgment to adapt and interpret data to meet the data collection requirements accurately and within established time constraints; Abstracting the diagnoses, procedures performed level of patient evaluation, drugs injected etc, for all inpatient stays; Work closely with members of the health care team to perform the coding activities with highest possible degree of accuracy; Reviews the patient record to ensure all conditions for which care was given have been documented by the physician in the proper sequence of importance, and all operations and procedures have been described appropriately and are related to clinical diagnosis recorded; Provides technical advice to the professional staff relative to the best method of recording diagnoses and operations to assure maximum reimbursement potential; Assists professional staff in diagnostic/procedural sequencing; Completes Patient Treatment File (PTF) in Quadramed and Vista by abstracting information, including clinical and demographic information, from the record; Responsible for retrospective coding as well as concurrent coding as necessary; Codes diagnoses, operations and procedures (inpatient and outpatient), which requires knowledge in a variety of coding systems, using the International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and HCPCS Level II Code Book (HCPCS) ensuring completeness and conformance to accepted VA directives, JC requirements, ICD coding conventions and guidelines for optimal Diagnostic Related Group (DRG) assignment; Codes information from the medial records of patients to generate a clinical care patient care database for the Medical Center; Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner; Participates in regular meetings with the objective of solving problems, brainstorming, educating physicians and others as to the coding policies and procedures of the facility, as well as promoting consistency of data collected; Takes the initiative in one-on-one provider training to improve medical record documentation for the episodes of care provided; Assists physician, ancillary, administrative personnel and other clinical staff and ward clerks with concurrent documentation requirements in compliance with coding guidelines; retrieving patient health care data from various sources such as consolidated health records, Computerized Patient Record System (CPRS), diagnostic, therapeutic indices or clinical logs for research, planning, budgeting and marketing projects; Stays alert to repeat written-in diagnoses/procedures on the same clinic form and notifies the supervisor for corrective action; Gathers information for time studies or quality assessment reports; Performs quantitative/qualitative analysis of outpatient/inpatient medical records to identify areas of the medical record, which contain incomplete, inaccurate or inconsistent documentation; Maintains confidentiality of all records and documents regarding patients; Performs other related record reviews and coding as requested and assigned by the lead or supervisor. Work Schedule: Monday - Friday, 7:30am-4:00pm or 8:00am-4:30pm Telework: Ad-hoc Telework only Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized