Medical Records Technician (Coder-Outpatient and Inpatient)

Full Job Description

The Tuscaloosa, AL VA Healthcare System is seeking Medical Records Technicians (Coder-Outpatient and Inpatient)!

MRT (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, multi-specialty 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. 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: 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 4 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.

Grade Determinations: (1) Medical Records Technician (Coder-Outpatient and Inpatient), GS-5 (a) Experience.

One year of creditable experience equivalent to the next lower grade level; OR , (b) Education.

Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university recognized by the U.S.

Dept 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.

(c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i.

Ability to use health information technology and software products used in MRT (Coder) positions (ie, the electronic health record, coding & abstracting software. ii.

Ability to navigate through and abstract pertinent information from health records. iii. 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, & disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation.

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

Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, &the ability to follow-up on pending issues.

(2) Medical Records Technician (Coder-Outpatient and Inpatient), GS-6 (a) Experience. One year of creditable experience equivalent to the next lower grade level.

(b) 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 outpatient coding & evaluate the adequacy of the documentation. ii.

Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, & support the assigned codes.

This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. iii.

Ability to apply laws and regulations on the confidentiality of health information (ie, Privacy Act, Freedom of Information Act, & HIPAA). iv.

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

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

vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

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

(b)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 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.

ii.

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.

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.

Please see journey grade level requirements under Education sections. Major Duties:

Total Rewards of a Allied Health Professional This position is located in the Health Information Management (HIM) section at the Tuscaloosa VA Medical Center.

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.

MRT (Coder) may also provide education related to coding and documentation.

Major duties may include, but are not limited to: Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.

Coding systems 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 (E/M) code to ensure ethical, accurate, and complete coding.

Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

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 within established timelines.

Research references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.

Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.

Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays; 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.

Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty 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.

Uses basic knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery; receives guidance from experienced coder to interpret instructional notations or to bundle encounters or to identify non-billable encounters.

Work Schedule: Monday-Friday 8AM-4:30PM. Work schedule subject to change based on agency needs.

Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases 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.

Functional Statement #: 60245F, 60246F, 60250F, 60256F Permanent Change of Station (PCS): Not authorized