Medical Records Technician (Outpatient/Inpatient Coder) GS-4/5/6/7/8

About the role

This job involves selecting and assigning codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties include a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services.

Responsibilities

• Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Coding all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Review provider health record documentation to ensure it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Query clinical staff with documentation requirements to support the coding process.
• Enter and correct information that has been rejected, when necessary.
• Correct any identified data errors or inconsistencies.
• Ensure audit findings have been corrected and refiled.
• Use various computer applications to abstract records, assign codes, and record and transmit data.

Requirements

Basic Requirements:

• Experience: 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 AAS 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, or Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in medical terminology - anatomy and physiology - medical coding - and introduction to health records, 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:

  • 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
  • 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

  Qualifications

  • Apprentice/Associate Level Certification through AHIMA or AAPC
  • Mastery Level Certification through AHIMA or AAPC
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS

  Skills & Abilities

  • Ability to use health information technology and various office software products used in MRT Coder positions, such as the electronic health record - coding and abstracting software, etc.
  • Ability to navigate through and abstract pertinent information from health records.
  • Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
  • 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 documentation.
  • Knowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelines.
  • Ability to manage priorities and coordinate work to complete duties within required timeframes - and the ability to follow-up on pending issues.

  Pay

  Salary Range: GS-4 to GS-8

  Schedule

  Monday - Friday 7:30 a.m- 4:00 p.m or 8:00 a.m- 4:30 p.m