Medical Records Technician (Outpatient/Inpatient Coder) GS-4/5/6/7/8

Summary

Outpatient/Inpatient (Coder) select codes from current versions of ICD CM - PCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis - complications/major complications - comorbid/major comorbid conditions - surgery - and procedures for assignment of diagnosis related groups (DRG) -and/or assigning CPT/HCPCS codes.

Qualifications

Basic Requirements:

• 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 AAS 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: Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• GRADE DETERMINATIONS AND ASSIGNMENTS
• Medical records Technician Coder Outpatient/Inpatient GS-4 Experience or Education- None beyond basic requirements above
• Medical records Technician Coder Outpatient/Inpatient GS-5 Experience
• One year creditable experience equivalent to the next lower grade level OR Education
• Successful completion of a BAS 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 Knowledge Skills & Abilities In addition to the experience - the candidate must demonstrate all of the following KSAs: 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 and outpatient episodes of care 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
• Medical records Technician Coder-Outpatient/Inpatient GS-6 Experience
• One year creditable experience equivalent to the next lower grade level AND Demonstrated Knowledge - Skills & Abilities
• In addition to the experience - the candidate must demonstrate all of the following 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 accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios
• 4
• 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
• Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) - and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG)
• 5
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG
• Medical records Technician Coder Outpatient/Inpatient GS-7 Experience
• One year creditable experience equivalent to the next lower grade level AND Demonstrated Knowledge - Skills & Abilities
• In addition to the experience - the candidate must demonstrate all of the following KSAs: 1
• Skill in applying current coding classifications to a variety of inpatient and outpatient 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 inpatient and outpatient 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.
• Medical Records Technician Coder Outpatient and Inpatient GS-8 Experience
• One year of creditable experience equivalent to the next lower grade level - AND Demonstrated Knowledge - Skills & Abilities
• In addition to the experience above - the candidate must demonstrate all of the following 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
• This includes the ability to read and understand the content of the health record - the terminology - the significance of the comments - and the disease process/pathophysiology of the patient
• 2
• Ability to accurately perform the full scope of outpatient coding - including ambulatory surgical cases - diagnostic studies and procedures - and outpatient encounters - and inpatient facility coding - including inpatient discharges - surgical cases - diagnostic studies and procedures - and inpatient professional services
• 3
• 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 completing assignments using incomplete or inadequate guidelines
• The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to the full performance level of a GS-8.
  
  

Duties

• This job opportunity announcement (JOA) will be used to fill 1 full-time and permanent Medical Records Technician (Outpatient/Inpatient Coder) vacancy(s) at the Memphis - TN Veteran Affairs Medical Center (VAMC) - with Business Office Service
• The technician is assigned to the Health Information Management Section (HIMS) - coding/analysis unit - VAMC Memphis - TN
• Outpatient/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
• Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis - complications/major complications - comorbid/major comorbid conditions - surgery - and procedures for accurate assignment of diagnosis related groups (DRG) - and/or assigning CPT/HCPCS codes for inpatient professional 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 medical/specialty diseases processes - patient injuries - and all medical procedures in a wide range of inpatient settings and specialties
• They directly consult with the clinical staff for clarification of conflicting - incomplete - or ambiguous clinical data in the health record
• They must abstract - assign - and sequence codes into encoder software to obtain correct DRG - support medical necessity - resolve encoder edits - and ensure codes accurately reflect services rendered
• They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature
• They query clinical staff with documentation requirements to support the coding process
• They also enter and correct information that has been rejected - when necessary
• They correct any identified data errors or inconsistencies
• They ensure audit findings have been corrected and refiled
• They 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
• Work Schedule: Monday - Friday 7:30 a.m
• - 4:00 p.m
• or 8:00 a.m
• - 4:30 p.m
• Virtual: This is not a virtual position
• Position Title/Functional Statement #: 50289-F Preferred Experience: Inpatient ambulatory surgery coding experience
• References: VA Handbook 5005/122 - Part II - Appendix G57 Physical Requirements: The work is primarily sedentary
• There is walking - bending & reaching required such as for filing or locating material & carrying items such as reports - documents/supplies.