Medical Records Technician (Coder) Auditor

Full Job Description

Position is located in the Health Information Management (HIM) section at the Business Office at the Bay Pines VA Healthcare System (BPVAHCS).

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, multi­specialty clinics, and specialty centers.

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: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.

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, legal aspects of health care, and introduction to health records).

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 towards meeting basic experience requirements.

The following experience and educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management courses.

Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and 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.

The training program may be substituted on a month- for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures.

Certification - Persons hired or reassigned to MRT (Coder) Auditor positions in the GS-0675 series must have at least one of the following listed: 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).

Mastery Level Certification through AHIMA or AAPC 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).

Note: A copy of your current certification must be submitted with your application.

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: MRT (Coder) Auditor - GS-9 - It is a requirement to have at least one year of specialized experience equivalent to the journey grade level (GS-8) of a MRT (Coder) which are: 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 Demonstrated Knowledge, Skills, and Abilities (KSAs) - GS-9 - In addition to the above required experience, the candidate must demonstrate all of the following technical KSAs and demonstrate the potential to acquire the assignment-specific KSAs: 1.

Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 2.

Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. 3.

Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. 4.

Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. 5.

Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. Preferred Experience: 3 years inpatient coding experience required.

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-09.

Physical Requirements: The work is performed in an office setting which adequately lighted, heated and ventilated. The physical demands of the work are generally minor.

The work is primarily sedentary although, there is some walking, bending, carrying of bulky files and some extended periods of standing. Major Duties:

Duties and task of the Medical Records Technician (Coder) - Auditor include, but are not limited to the following: Applies comprehensive 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.

Reviews assigned 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).

Applies 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 VAMC.

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

Assists 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.

Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.

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 ICD-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.

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.

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.

Maintains statistical databases to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Work Schedule: Monday - Friday 8:00am-4:30pm Telework: Available. Virtual: This is not a virtual position. Functional Statement #: 21773F Permanent Change of Station (PCS): Not authorized.