Medical Records Technician (Coder-Outpatient and Inpatient)

Coders are skilled in classifying medical data from patient health records in the hospital setting/physician-based settings. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes 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).

Qualifications:

Basic Requirements
Citizenship: Citizen of the United States.

English Language Proficiency: MRT Coders must be proficient in spoken and written English required by 38 USC 7403(f).

Experience and Education:
- 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
- An associates degree from an accredited college/university recognized by the U.S. Department of Education (major field of study in health information technology/health information management or related degree with at least 12 semester hours in HIT/HIM). 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. This must have led to eligibility for coding certification/certification examination and accredited by a national US Department of Education accreditor or comparable international accrediting authority at the time the program was completed. OR
- Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

• 6 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 HIT 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 US Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology and health record techniques and procedures. Also requires 6 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 one of the below. No other certifications are accepted.

• Apprentice/Associate Level Certification from AHIMA or AAPC
• Mastery Level Certification from AHIMA or AAPC
• Clinical Documentation Improvement Certification from AHIMA or ACDIS

Grandfathering Provision: All persons employed in VHA as a MRT Coder on December 10, 2019 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 met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: 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 GS8 level or placed in supervisory or managerial positions. 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.

Grade Determinations
GS-5: 1 year of creditable experience equivalent to the next lower grade level; OR successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.

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

GS-6: 1 year of creditable experience equivalent to the next lower grade level.

Demonstrated 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-7: 1 year of creditable experience equivalent to the next lower grade level.

Demonstrated 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-8: 1 year of creditable experience equivalent to the next lower grade level.

Demonstrated 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 findings, 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/or inpatient professional fee services coding.
-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.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: VA Directive and Handbook 5019, Employee Occupational Health Service.

The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

Responsibilities:

This is an open continuous announcement and will remain open until June 16, 2025. The initial cut-off date for referral of eligible applications will be 8 calendar days from opening of announcement, with subsequent cut-off dates. Eligible applications received after that date will be referred at regular intervals or as additional vacancies occur on an as-needed basis until positions are filled. Once selections are made, the announcement will be closed.

Duties and responsibilities 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 James Haley 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)(National Productivity Chart: Appendix A).
• 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 (in inpatient and outpatient settings) 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• 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.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• 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, and contacts supervisor as appropriate.
• 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.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
• 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: 7:30am - 4:00pm, Monday - Friday
Telework: Not available.
Virtual: This is not a virtual position.
Functional Statement #70250F, 70202F, 70204F, 70207F, 70209F Medical Records Technician (Coder-Outpatient and Inpatient)

Salary : $36,049