Medical Records Technician (Coder-Outpatient and Inpatient)

Summary This position is located in the Health Information Management (HIM) section at the Central Alabama Veterans Health Care System (CAVHCS). 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 center. Qualifications Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA PolicyEnglish Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C.7403(f)Experience or Education: 1year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of a health records~OR~ EducationAn associate's degree from an accredited college or university recognized by 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~OR~ Completion of an AHIMA approved coding program - or other intense coding training program of approximately 1year or more that included courses in anatomy and physiology - medical terminology - basic ICD diagnostic/procedural - & basic CPT codingTraining program must have led to eligibility for coding certification/certification examination - and sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor - or comparable international accrediting authority at time the program was completed;~OR~ Experience/Education CombinationEquivalent combinations of creditable experience & education are qualifying for meeting basic requirementsFollowing educational/training substitutions are appropriate for combining education and creditable experience:(a) 6months of creditable experience that indicates knowledge of medical terminology - general understanding of medical coding and health record - and 1year 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 Armed Forces or U.S. Maritime Service - under close medical & professional supervision - may be substituted on a month-for-month basis for up to 6months of experience provided training program included courses in anatomy - physiology - and health record techniques and proceduresAlso - requires 6 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 ACDISGrade Determinations :MRT (Coder-Outpatient and Inpatient): GS-4 Experience or EducationNone beyond basic requirementsGS-5 1year of creditable experience equivalent to next lower grade levelOR - (b) EducationSuccessful completion of 4years of education above high school leading to a bachelor's degree from an accredited college or university recognized by U.S. Dept 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 technologyKSAs In addition to experience above - and 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 & Reporting - & CPT guidelinesivAbility to apply knowledge of medical terminology - human anatomy/physiology - & disease processes to accurately assign codes to inpatient & outpatient episodes of care based on health record documentationvKnowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelinesviAbility to manage priorities & coordinate work to complete duties within required timeframes - & ability to follow-up on pending issuesGS-6 1year of creditable experience equivalent to next lower grade levelKSAs In addition to experience above - must demonstrate all of following KSAs: iAbility to analyze health record to identify all pertinent diagnoses & procedures for coding and to evaluate adequacy of documentationiiAbility to determine whether health records contain sufficient information for regulatory requirements - are acceptable as legal documents - are adequate for continuity of patient care - & support assigned codesThis includes ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliableiiiAbility to apply laws and regulations on confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and HIPAA)ivAbility to accurately apply ICD CM - PCS Official Conventions and Guidelines for Coding & Reporting - & 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 & 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 1year of creditable experience equivalent to next lower grade levelKSAsIn addition to experience above - demonstrate all of following KSAs: iSkill in applying current coding classifications to a variety of inpatient & outpatient specialty care areas to accurately reflect service and care provided based on documentation in health recordiiAbility to communicate with clinical staff for specific coding & documentation issues - such as recording inpatient & outpatient diagnoses & procedures - correct sequencing of diagnoses and/or procedures - and relationship between health record documentation & code assignmentiiiAbility to research & solve coding & documentation related issuesivSkill in reviewing & correcting system or processing errors & ensuring all assigned work is completevAbility to abstract - assign - & sequence codes - including complication or comorbidity/major complication or comorbidity (CC/MCC) - & POA indicators to obtain correct MS-DRGGS-8 1year of creditable experience equivalent to the next lower grade levelKSAs In addition to the experience above - demonstrate all of following KSAs: iAbility to analyze health record to identify all pertinent diagnoses & procedures for coding & to evaluate adequacy of documentationThis includes ability to read & understand content of health record - terminology - significance of comments - & disease process/pathophysiology of patientiiAbility to accurately perform full scope of outpatient coding - including ambulatory surgical cases - diagnostic studies and procedures - & outpatient encounters - & inpatient facility coding - including inpatient discharges - surgical cases - diagnostic studies & procedures - & inpatient professional servicesiiiSkill in interpreting & adapting health information guidelines that are not completely applicable to work - or have gaps in specificity - and 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/Current VHA employees in this occupation who meet the criteria may qualify under Grandfathering Provision described in VA Qualification StandardsFull performance level of this vacancy is GS-08Actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08Physical Requirements: See VA Handbook 5019. Duties Total Rewards of a Allied Health Professional Major duties may include - but are not limited to: Applies knowledge of medical record content - medical terminology - anatomy & physiology - diseases processes - and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional servicesSelects and assigns codes from the current versions of the International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and/or Healthcare Common Procedure Coding System (HCPCS)With instruction from a senior coder or supervisor learns to select diagnosis - operation - or procedure codes based on the accepted coding practices - guidelines - conventions and policyAssigns codes to documented patient care encounters (outpatient professional services)encounters are routine and less complex or for only one specialty or subspecialtySelects and assigns codes from the current version of the International Classification of Diseases (ICD) Clinical Modification (CM) - 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 AllocationMonitors 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 programsEstablishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations - instructions - and requirements for allowable reimbursementlinks the appropriate diagnosis to the procedure and/or determines level of E/M service providedUnderstands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notationsbundles encounters when appropriateidentifies non-billable encountersHCPCS codes are used per guidelinesCodes all Operating Room procedures reported in the Surgical Package of the VistA hospital systemapplies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suiteensures all procedures file to the appropriate Patient Care Encounter (PCE)adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical casesCodes diagnoses from paper forms for VA registries such as Agent Orange - Ionizing Radiation - Persian Gulf - Prisoner of War - etcWork Schedule: Monday - Friday - 8:00am - 4:30pm Telework: Available Virtual: This is not a virtual positionFunctional Statement #: 62247F - 62242F - 62241F - 62182F - and 62181F Relocation/Recruitment Incentives: Not Authorized - Permanent Change of Station (PCS): Not Authorized