MEDICAL RECORDS TECH (CODER) A

Full Job Description

Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding.

Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data.

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); 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 (Coder) Auditor, GS-9 Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder). 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).

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i.

Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). ii.

Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. iii.

Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. iv.

Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. v.

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: Physical aspects associated with work required of this assignment are typical for the occupation and would generally not require a pre-placement examination.

Exceptions: A pre-placement examination is required for any occupation or assignment that requires the operation of a government-owned or -leased motor vehicle in order to properly carry out assigned duties.

Examinations may also be required for any occupation or assignment that requires a pre-placement examination by virtue of another policy, regulation, or statute. Major Duties:

General Description For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity/difficulty, range of variety, and be performed by the incumbent at least 25% of the time.

Auditors must be able to perform all duties of a MRT -Coder. Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding.

Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data.

They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements.

They assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.

They provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data.

They use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes.

They perform prospective and retrospective coding audits and utilize results to identify documentation and coding inadequacies and re-educate clinical and coding staff based on audit results.

They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports.

They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all coded data is fully documented and supported.

They maintain statistical databases to track the results and validate the program. They identify patterns and variations in coding practices with regular reports to the medical staff and management.

Functions: Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care -purchased care- coding Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes, MSDRG, POA status, and discharge disposition values for inpatient health records.

Audit accurate and complete assignment of IC-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records.

Audit function includes evaluation of clinical documentation to support optimal code assignment.

Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data.

Facilitates improved overall quality, completeness and accuracy of coded data.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.

Responsible for performing audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.

Collaboratively works with coding staff and clinical staff to provide support and education on coding issues. Provides training and education to coding and clinical staff.

Researches complex coding issues and participates in process improvements related to coding.

Assists in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all coded data is fully documented and supported.

Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided.

As a technical expert in health information coding matters, provides advice and guidance on documentation and coding requirements.

Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines and audit standards, and results in appropriate data capture and reimbursement.

Analyze audit results and prepare summary feedback for individual coders and/or clinicians, making recommendations for improvement.

Provide coding consultation to coders and/or clinicians related to coding and documentation questions.

Work Schedule: Negotiable -between 630-0730 start, 1500 to 1600 end-, M-F Compressed/Flexible: Not Available Virtual: This is a virtual position.

Functional Statement #: 0000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station-PCS: Not Authorized