Medical Records Technician-Medical Coder

About the role

This position is in the Health Information Management (HIM) section of Patient Business Services (PBS) at the Columbus VA Ambulatory Care Center. 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

• Coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
• Outpatient Medical Record Technicians (Coder) select and assign codes to outpatient episodes of care - and/or inpatient professional services from current versions of ICD-10-CM - CPT - and HCPCS classification systems.
• Utilize the facility computer system and software applications to code - abstract - record - and transmit data.
• Correct any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Research references to resolve any questionable code errors contact a senior coder or supervisor when needed.
• Work within a team environment, support peers in meeting goals and deadlines, flexible and handle multiple tasks, work under pressure and cope with frequently changing projects and deadlines.
• Adhere 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.
• Adhere 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 needs.
• Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VMC.
• Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Perform a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture.
• Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Provide technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencing.
• Ensure provider documentation is complete and supports the diagnoses and procedures coded.
• Directly consult with the professional staff for clarification of conflicting or ambiguous clinical data.
• Report incorrect documentation or codes in the electronic patient health record.

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. Experience and Education: 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 OR 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) OR - 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. The 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 OR Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six (6) months of creditable experience that indicates knowledge of medical terminology - general understanding of medical coding and the health record - and one (1) year above high school - with a minimum of six (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 procedures Also - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder) Certification: 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 ACDI English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f)

Qualifications

May 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)

Pay

Competitive salary and regular salary increases

Schedule

Monday-Friday 7:30am-4:00pm