Medical Records Technician (Coder-Outpatient)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Phoenix VA Medical Center.

Medical Records Technicians (Coder-Outpatient) 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.

They 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: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of 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; 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 Outpatient) GS-04: Experience/Education: None beyond basic requirements GS-05: Experience/Education: 1 year of creditable experience equivalent to the GS-04 OR, Successful completion of a bachelor's degree from an accredited college/university recognized by the US 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.

AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).

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

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

Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. ???????

GS-06: Experience: 1 year of creditable experience equivalent to the GS-05 AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation.

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.

Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)).

Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios.

Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.

GS-07: Experience: 1 year of creditable experience equivalent to the GS-06 AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record.

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

Ability to research and solve coding and documentation related issues.

Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete GS-08: Experience: One year of creditable experience equivalent to the next lower grade level.

AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: 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.

Major Duties:

Total Rewards of an Allied Health Professional Utilizes computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes.

Performs audits of encounters to identify areas of noncompliance in coding. Facilitates improved overall quality, completeness, and accuracy of coded data.

Works with staff to ensure that regulations are met, or areas of weakness are identified and reported to the appropriate supervisor for corrective action.

Selects and assigns codes from the current version of several coding systems, including the 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.

Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and the structure of the patient health record.

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

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.

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

Work Schedule: Hours to be discussed during the interview process Remote: These approved positions are currently designated for a mid-term extension to the return to office mandate through October 2025.

While these positions may be filled remotely, the employee will be required to return to the office if the mid-term extension is not continued.

Therefore, all applicants must be located within 50 miles of a VA facility.

Compressed/Flexible: Not Available Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.

Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: This position is telework eligible but may be required to return to the office permanently at a later date.

Virtual: This is not a virtual position. Functional Statement #: 00000 Permanent Change of Station (PCS): Not Authorized