Medical Records Technician (Coder-Outpatient)

Summary

THIS IS NOT A REMOTE POSITION. This position is located in the Health Information Management (HIM) section at the Anchorage VA Medical Center.

About the Role

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.

Responsibilities

• Uses health information technology and software products used in MRT (Coder) positions (e.g. - the electronic health record - coding and abstracting software - etc.)
• Navigates through and abstracts pertinent information from health records
• Applies knowledge of medical terminology - anatomy and physiology - and disease processes to accurately assign codes to outpatient/ambulatory surgery records - based on health record documentation
• Manages priorities and coordinates work - in order to complete duties within required timeframes - and follows up on pending issues
• Analyzes the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluates the adequacy of the documentation
• Communicates with clinical staff for specific coding and documentation issues - such as recording diagnoses and procedures - ensuring the correct sequencing of diagnoses and/or procedures - and verifying the relationship between health record documentation and coder assignment
• Reviews and corrects system or processing errors and ensures all assigned work is complete
• Performs a comprehensive review of the electronic health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• Provides technical support in the areas of regulations
• Consults with the professional staff for clarification of conflicting or ambiguous clinical data
• Codes inpatient professional fee services for identified inpatient admissions
• Codes all identified surgical procedures

Qualifications

• 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
• 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)
• 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
• Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements
• 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
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f)
• Apprentice/Associate Level Certification through AHIMA or AAPC - Mastery Level Certification through AHIMA or AAPC - Clinical Documentation Improvement Certification through AHIMA or ACDIS

Benefits

• Total Rewards of a Allied Health Professional: Completes diagnostic and procedural coded data are necessary for research - epidemiology - outcomes and statistical analysis - financial and strategic planning - reimbursement - evaluation of quality of care - and communication to support the patient's treatment
• Selects and assigns codes from the current version of several coding systems to include ICD - CPT - and/or HCPCS
• 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
• Maintains a comprehensive review of the electronic health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• Supports the patient's treatment by assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided
• Ensures provider documentation is complete and supports the diagnoses and procedures coded
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data
• Reports incorrect documentation or codes in the electronic patient health record
• Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the electronic health record
• Utilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA databases
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines
• Researches references to resolve any questionable code errors - contacts supervisor as appropriate
• Codes inpatient professional fee services for identified inpatient admissions
• Codes all identified surgical procedures