Medical Records Technician (Coder-Outpatient)

Summary

This position is located in the Health Information Management (HIM) section at the Central Virginia Health Care System - Fredericksburg Virginia. 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.

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

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) Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) - (2) - or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS 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)
• Grade Determinations: Medical Records Technician (Coder- Outpatient) GS-8 Experience
• One year of creditable experience equivalent to the next lower grade level
• Examples of this experience includes but not limited to: Performs coding on outpatient episodes of care and/or inpatient professional services
• Selects and assign codes from current versions of ICD CM - CPT - and HCPCS classification systems
• Reviews record documentation to abstract all required medical - surgical - ancillary - demographic - social and administrative data - with minimal guidance from higher level MRTs (Coder)
• Reviews 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
• Reviews 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
• Uses various computer applications to abstract records - assign codes - and record and transmit data
• AND
• Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following 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
• 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 - 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 (Coder) 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
• MRTs (Coder) ensure audit findings have been corrected and refiled
• They also use various computer applications to abstract records - assign codes - and record and transmit data
• MRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unit
• Preferred Experience: Multi-specialty outpatient coding experience 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-8. Physical Requirements: The work is primarily sedentary
• Typically - the employee may sit comfortably to do the work
• However - there may be some walking
• standing
• bending
• No special physical demands are required to perform the work.
  
  

Duties

• Total Rewards of a Allied Health Professional 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
• Specific Functions: 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
• 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
• 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)
• 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
• Reviews and codes assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals - Emergency Rooms - military facilities - etc
• Codes all Operating Room 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
• Establishes the primary and secondary diagnosis and procedure codes for outpatient 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
• Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations
• bundles encounters when appropriate
• identifies non-billable encounters
• 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
• Conducts re-reviews of codes abstracted for outpatient 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 Work Schedule: Monday-Friday
• 8:00am - 4:30 pm
• 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 Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized