Medical Records Technician (Coder-Outpatient)

Summary

This position is in the Health Information Management Service (HIMS) at the James J. Peters VA Medical Center. The Medical Records Technician (MRT) (Coder-Outpatient) 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:

• 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 Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• 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
• 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: 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)
• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either below: Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• 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)
• Grade Determinations: In addition to the basic requirements for employment - candidates must meet the following grade-determining criteria for placement at grade levels specified
• MRT (Coder-Outpatient) MRT - GS-4: Experience or Education
• None beyond basic requirements
• MRT - GS-5: Experience
• One year of creditable experience equivalent to the next lower grade level
• OR - Education
• Successful completion of four years of education above high school leading to 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
• Demonstrated KSAs: i
• Ability to use health information technology and software products used in MRT (Coder) positions (e.g. - the electronic health record - coding and abstracting software - etc.)
• ii
• Ability to navigate through and abstract pertinent information from health records
• iii
• Knowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines
• iv
• Ability to apply knowledge of medical terminology - human anatomy/physiology - and disease processes to accurately assign codes to outpatient/ambulatory surgery records - based on health record documentation
• v
• Knowledge of The Joint Commission requirements - Centers for Medicare and Medicaid Services (CMS) - and/or health record documentation guidelines
• vi
• Ability to manage priorities and coordinate work - in order to complete duties within required timeframes - and the ability to follow-up on pending issues
• MRT - GS-6: Experience
• One year of creditable experience equivalent to the next lower grade level
• Demonstrated KSAs: i
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation
• ii
• 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
• iii
• Ability to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and Health Insurance Portability and Accountability Act (HIPAA))
• iv
• Ability to accurately apply the ICD CM - procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines to coding scenarios
• v
• Comprehensive knowledge of current classification systems - such as ICD CM - CPT - and HCPCS - and skill in applying said classifications to outpatient episodes of care - and/or inpatient professional services based on health record documentation
• MRT - GS-7: Experience
• One year of creditable experience equivalent to the next lower grade level
• Demonstrated KSAs: i
• Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record
• ii
• Ability to communicate 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
• iii
• Ability to research and solve coding and documentation related issues
• iv
• Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
• MRT - GS-8: Experience
• One year of creditable experience equivalent to the next lower grade level
• Demonstrated KSAs: i
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation
• This includes the ability to read and understand the content of the health record - the terminology - the significance of the findings - and the disease process/pathophysiology of the patient
• ii
• Ability to accurately perform the full scope of outpatient coding - including ambulatory surgical cases - diagnostic studies and procedures - and outpatient encounters - and/or inpatient professional fee services coding
• iii
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity - and the ability to use judgment in completing assignments using incomplete or inadequate guidelines
• Preferred Experience: Minimum one year of surgery coding experience.
  
  

Duties

• Temporarily eligible for Remote work within 50 miles of a VA Medical Center
• May fall under the Presidential Memorandum tiled \"Return to In-Person Work\" which will require you to go into the office if the exemption is not approved at the next review
• Duties may include but are not limited to: MRT GS-04 Assignment
• Entry level MRTs (Coder) receive close guidance from more experienced MRTs
• Outpatient MRTs select and assign codes from current versions of ICD Clinical Modification (CM) - CPT - and HCPCS classification systems
• MRTs review record documentation to abstract all required medical - surgical - ancillary - demographic - social and administrative data - and query clinical staff - as appropriate - with close guidance from higher level MRTs
• They use various computer applications to abstract records - assign codes - and record and transmit data
• They ensure audit findings have been corrected and refiled
• MRT GS-05 Assignment
• Developmental level 1 MRTs (Coder) receive guidance from more experienced MRTs for more complex coding procedures
• Outpatient MRTs select and assign codes to outpatient episodes of care - and/or inpatient professional services from current versions of ICD CM - CPT - and HCPCS classification systems
• They review record documentation to abstract all required medical - surgical - ancillary - demographic - social and administrative data - and query clinical staff - as appropriate - with guidance from higher level MRTs
• MRT GS-06 Assignment
• Developmental level 2 positions as MRTs (Coder) receive intermittent monitoring
• Outpatient MRTs may perform coding on outpatient episodes of care and/or inpatient professional services
• They select and assign codes from current versions of ICD CM - CPT - and HCPCS classification systems
• They review record documentation to abstract all required medical - surgical - ancillary - demographic - social and administrative data - and query clinical staff - as appropriate - with limited guidance from higher level MRTs
• MRT GS-07 Assignment
• Developmental level 3 MRTs (Coder) receive minimal monitoring
• Outpatient MRTs perform coding on outpatient episodes of care and/or inpatient professional services
• They select and assign codes from current versions of ICD CM - CPT - and HCPCS classification systems
• They review record documentation to abstract all required 9 medical - surgical - ancillary - demographic - social and administrative data - with minimal guidance from higher level MRTs
• They 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
• They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature
• MRTs in this assignment also query clinical staff with documentation requirements to support the coding process
• MRT GS-08 Assignment
• Outpatient MRTs (Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases - diagnostic studies and procedures - outpatient encounters - and/or inpatient professional services
• Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnoses - CPT/HCPCS codes for surgeries - procedures and evaluation - and management services
• They 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
• They code all complicated and complex disease processes - 10 patient injuries - and all procedures in a wide range of ambulatory settings and specialties
• They also directly consult with the clinical staff for clarification of conflicting - incomplete - or ambiguous clinical data in the health record
• MRTs must abstract - assign - and sequence codes into encoder software to support medical necessity - resolve encoder edits - and ensure codes accurately reflect services rendered
• They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature
• They also query clinical staff with documentation requirements to support the coding process
• They enter and correct information that has been rejected - when necessary
• Work Schedule: Monday to Friday - 8:00am to 4:30pm EST Remote: The option for remote work will be assessed continuously - and the selected individual may need to return to a VA office if required
• The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs)
• Telework: Not applicable - this is a remote position
• Virtual: This is not a virtual position
• Functional Statement #: PD13980F - PD13981F - PD13982F - PD13983F - and PD13984F Permanent Change of Station (PCS): Not Authorized