Medical Records Technician (Coder-Outpatient)

Summary

This position is located in the Health Information Management (HIM) section at the Beckley VA Medical 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. These coding practitioners analyze and abstract patients' health records - and assign alpha numeric codes for each diagnosis and procedure.

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: (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
• 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
• Grade Determinations: Medical Records Technician (Coder-Outpatient) - GS-8 Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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
• 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
• 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
• Experience: One year of creditable experience equivalent to the next lower grade level
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• The full performance level of this vacancy is GS-08
• The actual grade at which an applicant may be selected for this vacancy is GS-08 Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service.
  
  

Duties

• Total Rewards of a Allied Health Professional Major Duties may Include: Selects and assigns codes from the current version of several coding systems to include ICD - CPT - and/or HCPCS
• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC
• 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
• 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 electronic health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• 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
• Ensures 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
• Utilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA databases
• 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 Microsoft Outlook - Excel - Word - and Teams
• competent in use of electronic health record applications 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
• Establishes the primary and secondary diagnosis and procedure codes for outpatient professional and technical fee encounters following applicable regulations - instructions - and requirements for allowable reimbursement
• links the appropriate diagnosis to the procedure and/or determines level of E/M service provided
• Codes all identified surgical procedures
• applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite
• adds Anesthesia and Pathology for all billable surgical cases - which may involve creating the encounters
• May be required to review and enter coded data from paid Community Care claims using documentation (e.g. - hard-copy claims) obtained from non-VA facilities
• May code diagnoses for VA registries such as Agent Orange - Ionizing Radiation - Persian Gulf - Prisoner of War - etc
• Work Schedule: Monday - Friday - 8am - 4:30pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases
• When setting pay - a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade)
• 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) Selected applicants may qualify for credit toward annual leave accrual - based on prior [work experience] or military service experience
• 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: Not Available Virtual: This is not a virtual position
• Functional Statement #:512-260151-F Permanent Change of Station (PCS): Not Authorized