Medical Records Technician (Coder)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Edward Hines Jr. VA Hospital.

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.

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: 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: Must have one of the following: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC.

Clinical Documentation Improvement Certification through AHIMA or ACDIS. IN ADDITION TO BASIC REQUIREMENTS, YOU MUST MEET THE FOLLOWING GRADE REQUIREMENTS.

Grade Requirements: GS-4: Experience or Education. None beyond basic requirements.

GS-5: Experience: One year of creditable experience equivalent to the next lower grade level; OR, Education: Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.

In addition to the experience above, you must demonstrate all of the following KSAs: 1.

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.). 2.

Ability to navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. 4.

Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.

5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 6.

Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

GS-6: Experience: One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, you must demonstrate all of the following KSAs: 1.

Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2.

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. 3.

Ability to apply laws and regulations on the confidentiality of health information. 4.

Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. 5.

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

6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7: Experience: One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, you must demonstrate all of the following KSAs: 1.

Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.

2.

Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.

3. Ability to research and solve coding and documentation related issues. 4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. 5.

Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.

GS-8: Experience: One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, you must demonstrate all of the following KSAs: 1.

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. 2.

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.

3.

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.

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: See VA Directive and Handbook 5019, Employee Occupational Health Service. Major Duties:

This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties.

MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.

Inpatient/Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs.

This position is eligible for remote/telework after successful completion of new employee 90-day probationary period.

The employee must adhere to all hospital and departmental policies and procedures including using professional judgement to accommodate onsite meetings and trainings.

The employee must maintain a satisfactory performance evaluation to be allowed to continue to work remotely/telework.

Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.

Patient encounters are often complicated and complex requiring extensive coding expertise.

Applies 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.

Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

Adheres 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.

Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) 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.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

Patient health records may be paper or electronic.

Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).

Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff.

All diagnoses and procedure codes are selected from the current version of the ICD coding system.

Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.

Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.

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

Codes inpatient professional fee services for identified inpatient admissions.

Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.

Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.

Other duties as assigned.

Work Schedule: Monday-Friday 7:30am-4:00pm Telework: Ad-hoc telework eligibility may be authorized Virtual: This is not a virtual position Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required Salary Ranges: GS-4: $40,701 - $52,915 GS-5: $45,538 - $59,200 GS-6: $50,762 - $65,990 GS-7: $86,409 - $73,333 GS-8: $62,470 - $81,208