This position is located in the Planning, Performance, & Development Service, Health Information Management (HIM) section at the South Texas Veterans Health Care System. MRTs are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.
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. Experience and Education (1) 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, (2) 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) (Transcripts Required) OR, (3) 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 (Transcripts Required) OR, (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.(Transcripts Required) The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical 4 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. (b) 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. Must have one of the following: (1) Mastery Level Certification through AHIMA or AAPC. (2) 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. 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: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: Medical Records Technician-Clinical Documentation Improvement Specialist (Outpatient/Inpatient), GS-09 Experience. At least one year of creditable experience equivalent to the GS-8 Medical Records Technician (Coder - Outpatient and Inpatient) OR; Education. An associate's degree or higher and three (3) years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records)(Transcripts Required) OR; Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement OR; Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Demonstrated Knowledge, Skills, and Abilities. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record, including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Ability to establish and maintain strong verbal and written communication with providers. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. You must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators. Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the GS-09 . Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds.
Major Duties: Reviews overall quality & completeness of clinical documentation. Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures. Provides education to clinical staff on outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, & clinic visits. Provides education to providers on the need for accurate & complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, & ensuring documentation supports the codes selected to the highest degree of specificity. Adheres to accepted coding practices, guidelines & conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, & complete coding. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, & other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions & resource needs. Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator & coordinate provider documentation education with the VERA coordinator. Monitors ever-changing regulatory & policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Assists facility staff with documentation requirements to completely & accurately reflect the patient care provided. Provides technical support in the areas of regulations & policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, & proper sequencing. Consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Searches patient health record to find documentation justifying code assignment. Queries the medical staff as necessary to obtain accurate/complete documentation. Uses computer applications in day to day activities & duties, such as Outlook, Excel, Word, & Access; competent in use of the health record applications (VistA & CPRS) as well as the encoder product suite. Conducts short courses, informational briefings, & conferences concerned with health record documentation. Ensures active intra-departmental training program is in place for the HIM staff. Determines training needs of extra-departmental professional & non-professional personnel. Participates in in-service programs conducted throughout the hospital. Facilitates overall quality/accuracy of health record documentation. Promotes appropriate clinical documentation through extensive interaction with physicians, other patient caregivers & HIM coding staff. Ensures the accuracy/completeness of clinical information used for reporting physician & medical center outcomes on an ongoing basis. Assists in the development of guidelines for data compatibility for compliance to improve the quality of clinical, financial, & administrative data to ensure that all information is fully documented/supported. Provides guidance for documentation requirements, liability issues, advance directives, informed consent, patient privacy, confidentiality, & state reporting, etc. Analyzes processes & recommends improvements in documentation as necessary. Assists in writing coding policies that reflect the required changes to enhance revenue through improved documentation. Reviews, analyzes, & interprets medical data to a variety of patient care & treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvement needs. Reviews appropriateness of patient working Diagnosis Related Group (DRG) & length of stay information by reviewing all clinical documentation, lab results, diagnostic information & treatment to ensure documentation reflects severity of illness, acuity & resource consumption. Participates in clinical rounds & may offer information on documentation, coding rules, & reimbursement issues. Maintains statistical database(s) to track the results in coding practices with regular reports to the medical staff & management. The CDIS is expected to strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical & illegal to maximize payment by means that contradict regulatory guidelines, e.g. upcoding, DRG creep, etc. Work Schedule: Monday - Friday: 7:30 AM - 4:00 PM OR 8:00 AM - 4:30 PM CST 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