Medical Record Technician (Coder Inpatient)

This position is located in the Health Information Management (HIM) section at the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). Medical Record Technician (Coder Inpatient) 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, multi­specialty clinics, and specialty centers.

Qualifications:

Basic Requirements:
Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)
English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required.
Experience and Education
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-Transcripts Submitted. 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 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. (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-Documentation Submitted. 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 ACDIS.

Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard 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.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service for requirements.

Grade Determinations:
GS-0675-4. Experience or education - none beyond the basic requirements.
GS-0675-5. Experience of one year of creditable experience equivalent to the next lower grade level; or Education. Successful completion of a bachelor'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 management or a related degree with a minimum of 24 semester hours in health information management or technology.
GS-5 KSA

1. Ability 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.).
2. Ability to navigate through and abstract pertinent information from health records.
3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation.
5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
6. Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues.

GS-0675-6. One year of creditable experience equivalent to the next lower grade level. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
GS-0675-6 KSAs:

1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
4. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
5. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation.
6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG)

GS-0675-7. One year of creditable experience equivalent to the next lower grade level. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review and record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance.
GS-0675-7 KSAs:

1. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
2. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
3. Ability to research and solve coding and documentation related issues.
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG.

***The GS-0675-8 (KSAs) qualification continues on Education Section below.

Responsibilities:

Total Rewards of a Allied Health Professional

Medical Record Technician (Coder Inpatient) primary duties include but are not limited to:

• Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC.
• Patient encounters are often complicated and complex requiring extensive coding expertise.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded.
• Reports incorrect documentation or codes in the electronic patient health record.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
• Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Codes all inpatient procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Reviews and codes assigned fee service Care in the Community inpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, military facilities, etc.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Monday thru Friday 8:00am to 4:30pm.
Recruitment Incentive (Sign-on Bonus): Not Authorized.
Permanent Change of Station (Relocation Assistance): Not Authorized
Telework: This position is telework eligible and exempted from return to office requirements. This position will be reviewed annually and do not imply permanent telework status. Current employees will be granted an exception to remain in the current duty station location if outside VISN 8.
Virtual: This is not a virtual position.
Functional Statement #: 21765F
Permanent Change of Station (PCS): Not Authorized
PCS Appraised Value Offer (AVO): Not Authorized

Salary : $36,409