Med Records Technician (Coder-Inpatient)

Full Job Description

This Medical Records Technician (Coder-Inpatient) position is located in the Health Information Management (HIM) section at the Robley Rex VA Medical Center.

NOTE: This position is remote work eligible and is currently on an extension from the return to office mandates.

Remote positions are reviewed bi-annually and do not imply permanent remote work status and may be required to comply with the return to office mandates in the future.

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.

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. See education section for specific educational requirements; OR, Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year.

See education section for additional information; 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 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.

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.

This is considered an entry level coding certification and is limited to certification obtained through the American Health Information Management Association (AHIMA), or the American Academy of Professional Coders (AAPC).

To be acceptable for qualifications, the specific certification must represent a comprehensive competency in coding across a wide range of services.

Stand-alone specialty certifications do not meet the definition of apprentice/associate level certification and are not acceptable for qualifications.

Certification titles may change and certifications that meet the definition of apprentice/associate level certification may be added/removed by the above certifying bodies.

However, current apprentice/associate level certifications include: Certified Coding Associate (CCA), Certified Professional Coder-Apprentice (CPC-A) and Certified Outpatient Coding Apprentice (COC-A).

(2) Mastery Level Certification through AHIMA or AAPC.

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).

(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement 3 Specialists (ACDIS).

To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation.

Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies.

However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.

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, the below qualification requirements must be met at the grade(s) in which you are applying.

Medical Records Technician (Coder-Inpatient), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Inpatient).GS-5 Experience.

One year of creditable experience equivalent to the next lower grade; OR, Education.

Successful completion of a bachelor's degree, 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.

AND, Demonstrated Knowledge, Skills, and Abilities.

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 and PCS Official Conventions and Guidelines for Coding and Reporting.

Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records 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-Inpatient), GS-6 Experience. One year of creditable experience equivalent to the next lower grade. AND, Demonstrated Knowledge, Skills, and Abilities.

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 and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.

Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation.

Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). Major Duties:

This position is located in the Health Information Management (HIM) section at the Robley Rex VA Medical Center.

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

MRT (Coder) may also provide education related to coding and documentation.

Duties include, but are not limited to: Select and assign codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).Review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.

Use variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the health record applications (VISTA and CPRS) as well as the encoder product suite.

Directly consult with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record.

May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG).Enter and correct information that has been rejected, when necessary.

Apply advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.

Adhere to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.

Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

Work Schedule: Monday-Friday, 07:30am - 04:00pm Telework: This position is designated as remote.

Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces.

The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.

Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order. Virtual: This is not a virtual position.

Functional Statement #: 40838F, 40839F, 40840F, 40841F, 40842F Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized