Inpatient (Coder) select codes from current versions of ICD CM, PCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG),and/or assigning CPT/HCPCS codes.
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 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. Certification. MRT (Coder) GS-0675 must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. Certified Coding Associate (CCA) Certified Professional Coder-Apprentice (CPC-A) Certified Outpatient Coding-Apprentice (COC-A) (2) Mastery Level Certification through AHIMA or AA Certified Coding Specialist - Physician-based (CCS-P) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Professional Coder (CPC) Certified Outpatient Coder COC) Certified Inpatient Coder (CIC) Certified Coding Specialist (CCS) (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. Clinical Documentation Improvement Practitioner (CDIP) Certified Clinical Documentation Specialist Experience/Education. (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding & the structure/format of a health record. (2) Education. An associate's degree from an accredited college/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 & physiology, medical coding & introduction to health records). (3) Completion of an AHIMA approved coding program /other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, the sponsoring academic institution must be accredited by a national U.S. Department of Education accreditor/comparable international accrediting authority at the time the program was completed. 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). 4) Experience/Education Combination. Equivalent combinations of creditable experience/education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & credible experience.(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, & 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/hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical 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, health record techniques & procedures. Also requires six additional months of creditable experience that is paid/non-paid employment equivalent to a MRT (Coder).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). 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 range of GS-8. Grade Determinations: Medical Records Technician (Coder-Inpatient), GS-8 (a) Experience. One year of creditable experience equivalent to the next lower grade level (b) Assignment. This is the journey level for this assignment. Inpatient MRTs(Coder) select/assign codes from current versions of ICD CM, PCS, and/or CPT & HCPCS classification systems for inpatient facility and/or professional services. 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 procedures for accurate assignment of diagnosis related groups (DRG),and or assigning CPT/HCPCS codes for inpatient professional services. Independently reviews & abstract clinical data from the record for documentation of diagnoses & procedures to ensure it is adequate & appropriate to support the assigned codes. Codes all complicated/complex medical/specialty diseases processes, patient injuries, & all medical procedures in a wide range of inpatient settings/specialties. Directly consults with clinical staff for clarification of conflicting, incomplete, ambiguous clinical data in the health record. Abstract, assign & sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits & ensure codes accurately reflect services rendered. Reviews provider health record documentation to ensure that it supports diagnostic & procedural codes assigned are consistent with required medical coding nomenclature. Queries clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. Corrects identified data errors inconsistencies. Ensure audit findings are corrected & refiled. Uses various computer applications to abstract records, assign codes & transmit data. MRTs (Coder) may be assigned to (c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Ability to analyze the health record to identify all pertinent diagnoses/procedures for inpatient coding and to evaluate the adequacy of the documentation. This includes the ability to read & understand the content of the health record, the terminology, the significance of the comments & the disease process/pathophysiology of the patient. ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services. iii. Skill in interpreting & adapting health information guidelines that aren't completely applicable to the work or have gaps in specificity & the ability to use judgment in completing assignments using incomplete/inadequate guidelines. Preferred Experience: Inpatient ambulatory surgery coding experience. 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. Physical Requirements: The work is primarily sedentary. There is walking, bending & reaching required such as for filing or locating material & carrying items such as reports, documents/supplies. Entering data, word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain.
This job opportunity announcement (JOA) will be used to fill full-time and permanent Medical Records Technician (Inpatient Coder) vacancy(s) at the Memphis, TN Veteran Affairs Medical Center (VAMC), with Business Office Service. The technician is assigned to the Health Information Management Section (HIMS), coding/analysis unit, VAMC Memphis, TN. Inpatient MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. 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 CPT/HCPCS codes for inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They must abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. Work Schedule: Monday - Friday 7:30 a.m. - 4:00 p.m. or 8:00 a.m. - 4:30 p.m. Compressed/Flexible: Negotiable with Supervisory staff once hired. Remote: Position is remote work eligible and is exempted from return to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status. Virtual: This is not a virtual position. Functional Statement # 50288F