Medical Records Technician (Coder Auditor-Outpatient and Inpatient)

Full Job Description

This position is located in the Health Information Management Service at the North Texas VA Health Care System.

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: (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.

English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

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

Specialized 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 in adequate guidelines.

Certification. Employees at this level must have a mastery level certification. Assignment.

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 database(s) 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.

Demonstrated Knowledge, Skills, and Abilities.

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 & present audit results, identify trends, and provide guidance to improve accuracy.

Skill in interpersonal relations & 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/. The full performance level of this vacancy is GS-9.

Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work.

Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site.

Incumbent may carry and lift light items weighing less than 15 pounds. Major Duties:

Medical Records Technician - Coder 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 are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, the appropriate workload is captured, and resources are properly allocated.

They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.

They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients.

They develop and/or update medical center policies pertaining to clinical documentation improvement. They serve as technical experts in health record content and documentation requirements.

They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review the appropriateness of and responses to queries through a review of query reports.

They review health record documentation, develop criteria, collect data, graph and analyze results, create reports, communicate orally and/or in writing to appropriate groups and leadership.

They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices when applicable.

They adhere to established documentation requirements outlined by the accrediting agency's guidelines, regulations, policies, and medical-legal requirements.

They monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education.

They are responsible for developing and implementing active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to meet the CDIS program objectives.

They provide training in small or large groups, educating clinical staff about current documentation standards and improving techniques, including accurate and ethical documentation practices.

They apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and accurately reflect medical necessity and level of service or procedure performed in the outpatient setting.

Work Schedule: Monday - Friday, 8:00am - 4:30pm Recruitment Incentive (Sign-on Bonus): Not Authorized Virtual: This is not a virtual position.

Remote: Yes-This position is Remote 100% Outside the Area (Remote work outside parent station.

Employee works 100% of the time in non-VA-owned or leased space outside the local commuting area of parent station.) Functional Statement #: 55077-F Note: This position is remote work eligible and is exempted from return to office requirements.

Remote exempted positions are reviewed annually and do not imply permanent remote work status