Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient))

About the role

The Summary Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)) is located in the Health Information Management (HIM) section of the Health Administration Service at the VA Maryland Health Care System.

Responsibilities

• Responsible for reviewing the overall quality and completeness of clinical documentation.
• Applies comprehensive 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 clinical documentation supports proper code selection and reporting of high quality healthcare data.
• Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.
• Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
• Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
• Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), CPT, and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Aids facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Reports incorrect documentation in the electronic patient health record.
• Adheres to accepted coding practices, guidelines and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding.
• 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.
• Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
• Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access.
• Competent in use of electronic health record applications as well as the encoder and/or CDI product suite.
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
• Ensures active intra-departmental training program is in place for the HIM staff.
• Determines and meets training needs of extra-departmental professional, paraprofessional, and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents, and participates in in-service programs conducted throughout the hospital.
• Facilitates improved overall quality, completeness, and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.

Requirements

Basic Requirements: - 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. - 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). - 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. - 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). - Experience/Education Combination Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. - Requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder-Outpatient and Inpatient). - Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. - English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f).

Qualifications

Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) - (2) - or (3) below:

• Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDI

Benefits

Grade Determinations: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) - GS-9: Experience: In addition to the basic requirements - candidates must meet one of the following:

• One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient) including:
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentationThis 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.
• 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.
• An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
• Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
• One year of experience in clinical documentation improvement.

Skills

In addition to the experience above - the candidate must demonstrate all of the following KSAs:

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record, including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record.
• Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
• Establish and maintain strong verbal and written communication with providers.
• Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
• Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS.
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
• Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff