Medical Records Technician (Coder-Outpatient and Inpatient)

Full Job Description

The Medical Records Technician (Coder - Outpatient and Inpatient) is located in the Health Information Management (HIM) Service at the Veterans Healthcare System of the Ozarks VA Medical Center.

The 2-page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below. 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.

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: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: i.

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.

ii.

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.

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

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.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: i.

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. ii.

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.

iii.

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.

Preferred Experience: Knowledge coding Inpatient and Outpatient encounters. 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-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-07 to GS-08.

Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position.

May require standing, lifting, carrying, sitting, stooping, bending, pulling and pushing.

May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.

Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated and ventilated.

However, the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations. Major Duties:

Total Rewards of a Allied Health Professional Medical Records Technician (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.

Duties may include but are not limited to: 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 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.

Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.

Ensures provider documentation is complete and supports the diagnoses and procedures coded. Consults with the professional staff for clarification of conflicting or ambiguous clinical data.

Reports incorrect documentation or codes in the electronic patient health record.

Utilizes the facility computer system and software applications to 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.

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).

Codes inpatient professional fee services for identified inpatient admissions.

Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.

Work Schedule: Monday - Friday, 7:00am - 3:30pm. Schedule subject to change based on the needs of the service.

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: Not available Virtual: This is not a virtual position.

Remote: Medical Coders were granted a 180-day mid-term extension from RTO for clinical staff. This position is currently remote.

Subject to change based on the needs of the organization.(In which case office space would be assigned by Supervisor at a local VA Facility/CBOC or Federal Agency).

Functional Statement #: 564-01607-F; 564-01608-F Permanent Change of Station (PCS): Not Authorized