This position is in the Health Information Management (HIM) section at the Washington DC VA Medical Center. MRTs (Coder) Auditor classify medical data from patient records in hospitals and physician settings, such as clinics and specialty centers. They analyze health records and assign codes for diagnoses and procedures using ICD, CPT, and HCPCS systems. They may also provide education on coding and documentation practices.
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: To be appointed under authority of 38 U.S.C., chapter 73 or 74, to serve in a direct patient-care capacity in VHA, applicants must be proficient in written and spoken English Experience and/or Education. (You must upload copies of your transcript to validate the education requirement) 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. 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: GS-9 Medical Records Technician (Coder) Auditor Experience. One year of creditable experience equivalent to the GS-8 level of a MRT (Coder). Experience includes: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines. Certification. Employees at this level must have a mastery-level certification. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), 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). Knowledge, Skills and Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of the following KSAs: Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
Duties included, but not limited to: Basic Functions: Utilizes medical terminology, anatomy, disease processes, treatments, diagnostics, medications, and procedures to select accurate codes. Reviews codes from ICD, CPT, and HCPCS systems for correctness. Follows coding guidelines to ensure ethical, accurate, and complete coding. Applies VERA program criteria to classify VA patients based on clinical conditions and resource needs. Monitors regulatory and policy changes to ensure coding compliance and data accuracy. Assists staff with documentation to accurately reflect patient care; provides technical support and clarifies clinical data. Searches records to find documentation justifying codes, leveraging knowledge of record organization. Uses computer applications (Outlook, Excel, Word, Access, VistA, CPRS, encoder) to perform daily tasks; maintains updated software. Specific Functions: Reviews and reports on performance for PTF, PCE, VERA, and non-VA medical care coding. Audits inpatient and outpatient records for accurate ICD-10, CPT, HCPCS, MS-DRG, POA. and discharge data, ensuring documentation supports code assignment. Assists coders in improving accuracy, provides guidance, and analyzes data to promote consistency and compliance. Enhances data quality and accuracy, supporting reporting of physician and center outcomes; provides ongoing education to the care team. Performs audits, develops criteria, analyzes results, creates reports, and communicates findings to leadership. Collaborates with coding and clinical staff to provide support. training, and research on complex coding issues. Develops guidelines to improve data quality, consistency, and compliance, ensuring accurate documentation, reducing denials, and maximizing reimbursement. Offers expert guidance on coding and documentation, staying current with regulations and standards. Analyzes audit results, provides feedback, and offers consultation to improve coding accuracy. Maintains databases to track coding patterns, generate reports, and support quality improvement efforts. Total Rewards of a Allied Health Professional Work Schedule: Monday - Friday 7:30am - 4:00pm Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position.