Medical Records Technician (Coder-Outpatient)

About the role

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings. These coding practitioners analyze and abstract patients' health records and assign alphanumeric codes for each diagnosis and procedure.

Responsibilities

• Selects 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).
• 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 coding.
• 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.
• Maintains compliance with coding changes to ensure accuracy of the facility database and all cost recovery programs.
• Reviews patient health records to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Aids facility staff with documentation requirements to fully reflect patient care provided.
• Consults with professional staff for clarification of clinical data and searches the patient health record for documentation justifying code assignment.
• Ensures provider documentation is complete and supports the diagnoses and procedures coded.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Uses a variety of computer applications in daily activities and duties, such as Outlook, Excel, Word, and Access.
• Uses competent skills in using the health record applications (VistA and CPRS) as well as the encoder product suite.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
• Works within a team environment, supports peers in meeting goals and deadlines, is flexible, handles multiple tasks, works under pressure, and copes with frequently changing projects and deadlines.

Requirements

Basic Requirements:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• English Language: MRTC's must be proficient in spoken & written English as required by 38 U.S.C.7403(f)
• Experience/Education: Must have one year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure & format of health records OR Have an associate's degree from an accredited college/university recognized by the US 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 & physiology, medical coding, & introduction to health records) OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 year or more that included courses in anatomy & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding OR Have an experience/education combination

Qualifications

• The following educational/training substitutions are appropriate for combining education & creditable experience:
• 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, & 1 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 US Maritime Service, under close medical & professional supervision, may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology, & health record techniques & procedures
• Also - requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRTC Certification: Persons hired or reassigned to MRTC positions in VHA must have one of the below: Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC Clinical Documentation Improvement Certification through AHIMA or ACDIS Grandfathering Provision: All persons employed in VHA as a MRTC on 12/10/19 are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation
• Grade Determinations: GS-4: Experience/Education: None beyond basic requirements GS-5: Experience/Education: 1 year of creditable experience equivalent to the GS-4 OR Successful completion of 4 years of education above high school leading to a bachelor's degree from an accredited college/university recognized by the 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 technology AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Ability to use health information technology & software products used in MRTC positions (e.g., the electronic health record, coding and abstracting software, etc.) Ability to navigate through & abstract pertinent information from health records Knowledge of the ICD CM & PCS Official Conventions & Guidelines for Coding & Reporting - & CPT guidelines Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation Knowledge of The Joint Commission requirements, CMS, or health record documentation guidelines Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, & the ability to follow-up on pending issues
• GS-6: Experience: 1 year of creditable experience equivalent to the GS-5 AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses & procedures for outpatient coding and evaluate the adequacy of the documentation Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, & support the assigned codes This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable Ability to apply laws & regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, & HIPAA) Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions & Guidelines for Coding & Reporting - & CPT guidelines to coding scenarios Comprehensive knowledge of current classification systems, such as ICD CM & PCS, CPT, & HCPCS, & skill in applying said classifications to outpatient episodes of care, or inpatient professional services based on health record documentation
• GS-7: Experience: 1 year of creditable experience equivalent to the GS-6 AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care or inpatient professional services to accurately reflect service & care provided based on documentation in the health record Ability to communicate with clinical staff for specific coding & documentation issues, such as recording diagnoses & procedures, ensuring the correct sequencing of diagnoses and/or procedures, & verifying the relationship between health record documentation & coder assignment Ability to research & solve coding & documentation related issues Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete
• GS-8: Experience: 1 year of creditable experience equivalent to the GS-7 AND Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, must also demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses & procedures for coding & to evaluate the adequacy of the documentation This includes the ability to read & understand the content of the health record, the terminology, the significance of the findings, & the disease process/pathophysiology of the patient Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies & procedures, & outpatient encounters, or inpatient professional fee services coding Skill in interpreting & adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, & the ability to use judgment in completing assignments using incomplete or inadequate guidelines

Benefits

Competitive salary and regular salary increases

Pay

Competitive salary and regular salary increases

Schedule

TBD

References

For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards