Medical Records Technician Coder (Outpatient and Inpatient)

Full Job Description

This position is located in the Health Information Management (HIM) section of the Business Office at the Orlando VA Healthcare System.

MRTs (Coders) 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.

Please read the duties section of this announcement for further information on remote work status.

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. English Language Proficiency.

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

***ALL APPLICANTS MUST POSSESS A CURRENT MRT CERTIFICATION THROUGH AHIMA OR AAPC AND A COPY MUST BE SUBMITTED WITH YOUR APPLICATION.*** Grandfathering Provision.

All persons employed in VHA as a MRT (Coder) on the effective date of the VA Qualification Standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation.

Grandfathering Provision.

All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation.

For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

(2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.

(3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.

(4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

(5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

Grade Determinations: Medical Record Technician (Coder-In/Outpatient) (1) Medical Records Technician (Coder-In/Outpatient), GS-4 (a) Experience or Education. None beyond basic requirements.

(b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder).

Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM and the PCS, and/or, CPT and HCPCS classification systems for inpatient facility and/or professional services.

They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder).

They also use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled.

MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. Please see additional grade level requirements under Education and Additional Information sections.

Major Duties:

PLEASE NOTE: 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.

The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S.

Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements.

Any selected candidate must live within 50 miles of a VA Medical Center.

The Medical Records Technician (Coder-In/Outpatient), Assigns codes to documented patient care encounters (Inpatient /Outpatient facility and/or professional services) 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 E/M code to ensure ethical, accurate, and complete coding.

Also applies codes based on 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 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.

The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs 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.

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.

Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

Work Schedule: Full-time, Monday-Friday; Tour of duty will be set between 8:00am - 4:30pm EST.

Compressed/Flexible: NOT Available Telework: Yes-This position is telework eligible and exempted from return to office requirements.

This position will be reviewed annually and do not imply permanent telework status. Current employees will be granted an exception to remain in the current duty station location if outside VISN 8.

Functional Statement #: PD82470F, PD82471F, PD80133F, PD80134F, PD80135F, and PD80135F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required 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 (6-8 hrs.) although, there is some walking (1 hr.), bending (1 hr), and carrying of bulky files (1- 10 lbs.) and some extended periods of standing (2 hrs.).

**ALL APPLICANTS MUST POSSESS A CURRENT MRT CERTIFICATION THROUGH AHIMA OR AAPC. A COPY MUST BE SUBMITTED WITH YOUR APPLICATION.