Clinical Documentation Integrity Specialists (CDIS) must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient). CDIS's serve as the liaison between Health Information Management and clinical staff. They are responsible for facilitating improved overall quality, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients.
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 (ROI) must be proficient in spoken and written English Experience & 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); 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 OR (4) 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: (a) 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. (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. 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: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)), GS-9 (a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR, An associate's degree or higher and three 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); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order 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. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. iv. Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS). vii. Knowledge of 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. viii. 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. Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)), GS-9 (a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-inpatient); OR, An associate's degree or higher, and three 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); OR, Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement. Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification. Demonstrated Knowledge, Skills, and Abilities. i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. i i. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order 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. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels iv. Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators. vii. Knowledge of severity of illness, risk of mortality, and complexity of care. viii. 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-9. The actual grade at which an applicant may be selected for this vacancy is GS-9.
Duties/Functions: Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of inpatient records with an emphasis on improving documentation while the patient is still in-house while Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective review of outpatient encounters. Provides education to the providers on documentation improvement in the health record to include the impact of documentation on coding, quality measures and reimbursement. Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinates provider documentation education with the VERA coordinator. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and 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 and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the facility. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Queries providers for clarification of conflicting or ambiguous documentation. Identifies trends and opportunities to improve documentation. Uses a variety of computer applications in daily activities and duties, such as Outlook, Excel, Word, and Power Point and is competent in the use of the health record applications VistA and CPRS as well as the Solventum encoder product suite and WebV IRR suite of products for PTF completion, Encounter Completion and Compliance E-mail Tracking. Work Schedule: 7:30am-4pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 70210-F Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized