MEDICAL RECORDS TECHNICIAN (CODER) OCA

This position is located in Business Office, Health Information Management (HIM) Section, Atlanta 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.

Qualifications:

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
• (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) 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:
  • 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;
  • 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
  • Apprentice/Associate Level Certification through AHIMA or AAPC; OR
  • Mastery Level Certification through AHIMA or AAPC; OR
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS
• Medical Records Technician (Coder) Developmental Level 3 GS-675-7a) Experience. One year of experience equivalent to the next lower level.
• b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs.
• Skill in applying current coding classifications to a variety of specialty care areas 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 inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code 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.

References:
VA Handbook 5005, Part II Appendix G57.The full performance level of this vacancy is GS-8

Physical Requirements:
Light lifting, under 15 lbs, moderate carrying, 15-44 lbs, reaching above shoulder, use of fingers, standing 4-6 hours; hearing, aid permitted. Duties require extensive use of fingers to perform keyboarding and the ability to hear requests by phone and in person. Vision must be adequate to read and prepare documents.

Responsibilities:

• Theses coding practitioners analyze and abstract patients' health records and assign alpha-numeric coders for each diagnosis and procedure.
• To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS).
• MRT (Coder) may also provide education related to coding and documentations.
• This is the journey level for this assignment.
• MRTs (Coder at this level performs the full scope of inpatient and outpatient coding duties.
• MRTs (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.
• Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complication, comorbid/major comorbid conditions, surgery and procedures for accurate assignment of DRGs.
• Outpatient duties consist of the performance of a comprehensive review of documentation within the health record of accurately assign ICD-10-CM codes for diagnosis and complication, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services.
• Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
• They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstract, assign and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Query clinical staff with documentation requirements to support the coding process.
• Enter and correct information that has been rejected.
• Corrects any identified data errors or inconsistencies.
• Ensure audit findings have been corrected and refiled.
• Use various computer applications to abstract records, assign codes and record and transmit data.

Work Schedule: Open
Financial Disclosure Report: Not required

Salary : $57,353