Medical Records Technician-Coder Outpatient

Summary

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings. Practitioners analyze and abstract patients' health records - and assign alphanumeric codes for each diagnosis and procedure. To perform this task - they must possess expertise in International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS).

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: 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
• The training program must have led to eligibility for coding certification/certification examination - & the sponsoring academic institution must have been accredited by a national US Department of Education accreditor - or comparable international accrediting authority at the time the program was completed OR Have an experience/education combination
• 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 12/10/2019 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:GS4: Experience/Education: None beyond basic requirements GS5:Experience/Education: 1 year of creditable experience equivalent to the GS4 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. 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 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 - and 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 - and/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 GS6:Experience: 1 year of creditable experience equivalent to the GS5 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 and Guidelines for Coding and Reporting - and 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 - and/or inpatient professional services based on health record documentation GS7:Experience: 1 year of creditable experience equivalent to the GS6 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 and/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 GS8:Experience: 1 year of creditable experience equivalent to the GS7 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 - and/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 References: VA Handbook 5005/122 - Part II - Appendix G57 The full performance level of this vacancy is GS8
• The actual grade at which an applicant may be selected for this vacancy is in the range of GS4 to GS8 Physical Requirements: See VA Directive & Handbook 5019 - Employee Occupational Health Service.
  
  

Duties

• Total Rewards of a Allied Health Professional 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
• Also 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 that categorizes all VA patients into specific classes representing their clinical conditions and resource needs
• 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
• Performs a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• Patient health records may be paper or electronic
• The abstracted data has many purposes - for example - to profile the facility services and patient population - to determine budgetary requirements - to report to accrediting and peer review organizations - to bill insurance companies and other agencies - and to support research 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
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data
• Reports incorrect documentation or codes in the electronic patient health record
• Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record
• 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
• Independently researches references to resolve any questionable code errors
• contacts supervisor as appropriate
• 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
• 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
• flexible and handles multiple tasks
• works under pressure
• and copes with frequently changing projects and deadlines
• Work Schedule: Mon-Fri Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child
• Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Authorized Virtual: This is not a virtual position
• Functional Statement #:58872-O / 58873-O / 58874-O / 58875-O / 58876-O Permanent Change of Station (PCS): Not Authorized ***This position currently has a Return to Office (RTO) mid-term extension (180-days)
• Remote work is currently authorized
• however - candidates may be subject to return to office in the event policy changes or the exemption is not extended
• ***