Medical Records Technician (Coder - Outpatient and Inpatient)

Summary This position is in the Health Information Management (HIM) section at the Lt. Col. Luke Weathers - Jr. VA Medical Center. Medical Records Technicians (MRT) (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 Basic Requirements: 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 recordsOR - Education - Please see education below for detailsOR - 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 codingThe 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 completedOR - Experience/Education Combination - Please see information below under educationCertification - 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 ACDISNOTE: Mastery level certification is required for all positions above the journey levelhowever - for clinical documentation improvement specialist assignments - a clinical documentation improvement certification may be substituted for a mastery level certificationGrade Determinations: GS-4 MRT (Coder - Outpatient and Inpatient) - Experience or Education Requirement: None beyond basic requirementsGS-5 MRT (Coder - Outpatient and Inpatient) - Experience: In addition to meeting the basic requirements - to qualify for the GS-5 you must meet one of the following experience or education requirements: Experience: One year of creditable experience equivalent to the next lower grade levelOR 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 technologyDemonstrated Knowledge - Skills - and Abilities: In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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 recordsKnowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelinesAbility 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 documentationKnowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelinesAbility to manage priorities and coordinate work to complete duties within required timeframes - and the ability to follow-up on pending issuesGS-6 MRT (Coder - Outpatient and Inpatient) - Experience- One year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and Abilities: In addition to the experience above - the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentationAbility 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 codesThis includes the ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliableAbility to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and HIPAA)Ability to accurately apply the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT Guidelines to various coding scenariosComprehensive knowledge of current classification systems - such as ICD - CM - PCS - CPT - HCPCS - and skill in applying classifications to both inpatient and outpatient records based on health record documentationKnowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRGGS-7 MRT (Coder - Outpatient and Inpatient) - Experience: One year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and Abilities: In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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 recordAbility 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 assignmentAbility to research and solve coding and documentation related issuesSkill in reviewing and correcting system or processing errors and ensuring all assigned work is completeAbility to abstract - assign - and sequence codes - including complication or comorbidity/major complication or comorbidity (CC/MCC) - and POA indicators to obtain correct MS-DRGGS-8 MRT (Coder - Outpatient and Inpatient) (Full Performance Level) - Experience - One year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and Abilities - In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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 healthrecord - the terminology - the significance of the comments - and the disease process/pathophysiology of the patientAbility 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 servicesSkill 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 guidelinesReference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/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. Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service. Duties These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedureTo perform this task - they must possess expertise in International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Coding System (HCPCS)MRT (Coder) may also provide education related to coding and documentationDuties include but are not limited to the following: Diagnoses and procedures will be coded utilizing the current edition of ICD - Clinical Modification (CM) - and Procedure Coding System (PCS) - CPT - and/or HCPCSApplies knowledge of health record content - medical terminology - anatomy and physiology - disease processes - and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient servicesSelects and assigns code from the current version ICD - CPT - and/or HCPSReviews health record documentation to abstract all required medical - surgical - ancillary - demographic - social - and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic recordUtilizes the facility computer system and software applications to code - abstract - record - and transmit data to national VA databasesIdentify data errors are reviewed with a senior coder or the supervisor and corrections made as directedWork Schedule: Monday - Friday7:30 am - 4:00 pm or 8:00 am - 4:30 PM Telework: Not AvailableRemote: This position currently has a mid-term Return to Office (RTO) extension of 180 daysPlease note that this extension is subject to changeCandidates may be required to return to the office if agency policy is updated or if the exemption is not extendedMust be able to travel within 50 miles of a VA Facility if remote status is cancelledVirtual: This is not a virtual positionFunctional Statement #: 51347-F - 51348-F - 51349-F - 51349-5 - 000000 Relocation/Recruitment Incentives: Not AuthorizedPermanent Change of Station (PCS): Not Authorized.