Medical Records Technician (Coder-Outpatient and Inpatient)

Summary This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare 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 PolicyExperience and Education(1) ExperienceOne year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of a health recordsOR - (2) EducationAn 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 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 - (4) Experience/Education CombinationEquivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsThe following educational/training substitutions are appropriate for combining education and creditable experience: (a) 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(b) 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 proceduresAlso - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)CertificationPersons 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 ACDISMay 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) Medical Records Technician - GS-4 Experience or EducationNone beyond basic requirementsMedical Records Technician (Coder-Outpatient and Inpatient) - GS-5 ExperienceOne year of creditable experience equivalent to the next lower grade levelOR EducationSuccessful 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 AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: iAbility 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.)iiAbility to navigate through and abstract pertinent information from health recordsiiiKnowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelinesivAbility 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 documentationvKnowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelinesviAbility to manage priorities and coordinate work to complete duties within required timeframes - and the ability to follow-up on pending issuesMedical Records Technician (Coder-Outpatient and Inpatient) - GS-6 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: iAbility to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentationiiAbility 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 reliableiiiAbility to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and HIPAA)ivAbility to accurately apply the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT Guidelines to various coding scenariosvComprehensive 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 documentationviKnowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRGGS-7 and GS-8 Qualification Standards continued in education sectionPreferred Experience: NoneReference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/The full performance level of this vacancy is 08The actual grade at which an applicant may be selected for this vacancy is in the range of 04 to 08Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation - see Duties section for essential job duties of the positionMay require standing - lifting - carrying - sitting - stooping - bending - puling - and pushingMay be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employmentWork Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautionsthe area is adequately lighted - heated - and ventilatedHowever - the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations. 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 Procedure Coding System (HCPCS)MRT (Coder) may also provide education related to coding and documentationAssigns codes to documented patient care encounters (inpatient and outpatient)encounters are routine and less complex or for only one specialty or subspecialtyHas basic knowledge of medical terminology - anatomy & physiology - diseases - treatments - diagnostic tests - and medications to ensure proper code selectionSelects and assigns codes from the current version of one or more coding systems depending on regular/recurring dutiesCoding systems 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 codingAlso adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needsMonitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMCTimely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programsPerforms a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capturePatient health records may be paper or electronicThe 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 programsAssists facility staff with documentation requirements to completely and accurately reflect the patient care providedprovides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencingInsures provider documentation is complete and supports the diagnoses and procedures codedDirectly consults with the professional staff for clarification of conflicting or ambiguous clinical dataReports incorrect documentation or codes in the electronic patient recordExpertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient recordUtilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA database in AustinCorrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelinesIndependently researches references to resolve any questionable code errorscontacts supervisor as appropriateUses a variety of computer applications in day to day activities and dutiesWork Schedule: Monday-Friday7am-3:30pm Pay: Competitive salary and regular salary increasesPaid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a childChild Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Available ***This position currently has a Return to Office (RTO) mid-term extension (180-days)However - candidates may be subject to return to office in the event policy changes or the exemption is not extended.*** Virtual: This position may be filled at the facility where the position is located or virtual (i.e. - the employee may work at a VA facility or other VA-leased space other than the facility that is hiring the employee) and is authorized for teleworkFunctional Statement #: 00465F - 00466F - 00467F - 00468F - 00469F