Medical Records Technician (Coder)

PLEASE READ THIS ANNOUNCEMENT IN ITS ENTIRETY BEFORE BEGINNING THE APPLICATION PROCESS TO ENSURE YOU SUBMIT ALL THE REQUIRED DOCUMENTS.

This Job Opportunity Announcement will be used to fill a Medical Records Technician (Coder), GS-0675-00 position in the Business Office Service at the Cheyenne VA Health Care System, Cheyenne, WY.

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.

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 experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:

• Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses. OR
• 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.

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.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification

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 and Inpatient), GS-4
Experience or Education. None beyond basic requirements.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-5
Experience. One year of creditable experience equivalent to the next lower grade level;
OR
Education. 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. In addition to the experience above, the candidate must demonstrate KSAs which include but are not limited to:

• Ability to use health information technology and various office 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 inpatient and outpatient episodes of care based on health record documentation.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-6
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 KSAs which include but are not limited to:

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to 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 HIPAA).

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 KSAs which include but are not limited to:

• 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.
• 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.
• Ability to research and solve coding and documentation related issues.

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 KSAs which include but are not limited to:

• 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.

References: VA Handbook 5005/122 Part II Appendix G57

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

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

Responsibilities:

This position is located in the Health Information Management (HIM) section at the Cheyenne 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.

Major duties include but are not limited to:

Basic Functions:

• Assigns codes to documented patient care encounters (inpatient and/or 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 (E/M) 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.
• 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.

Specific Functions:

• 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). 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.
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay admissions to reflect all patient conditions and care up to the census date or to the requested billing date.
• Reviews and codes assigned fee service Care in the Community patient encounters (inpatient and outpatient) using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Flexible
Virtual: This is a virtual position.
Functional Statement #: 53019-A
Financial Disclosure Report: Not required

Salary : $33,693 - $67,231