Medical Records Technician (Coder-Outpatient and Inpatient)
The Medical Records Technician (Coder Inpatient and Outpatient) is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided. Major duties and functions include but are not limited to:
Navigate through health records to find needed information to assign codes to encounters (inpatient or outpatient) for the specialty and subspecialty health care services Select and assign codes from the current version of one of more coding system (ICD---CM, CPT, HCPCS) Apply laws and regulations on the confidentiality of health information Ensure that the provider documentation is complete and support the correct sequencing of diagnosis and procedures coded Analyze the medical record to identify all pertinent diagnosis and procedure for coding and to evaluate the adequacy of the documentation Conduct re-review of ICD-10 codes to determine if based on the documentation the specific VERA coding requirements were followed Review and code inpatient professional fee services for identified inpatient admissions for Non-VA Care Establish the primary and secondary diagnosis and procedure codes for billable outpatient encounters Code all surgery procedures in the surgical package in Nuance, ensure all procedures file to the appropriate Patient Care Encounter (PCE), and add Anesthesia and Pathology codes ot the PCE encounter Update codes for current inpatient Long-Term Care and Contract Nursing Home admissions Perform other related duties as assigned Work Schedule:
Full-Time, Monday - Friday, Day Shift Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement. 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-675 series 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 Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure & format of health records. OR Education. 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 and physiology, medical coding, & introduction to health records) (TRANSCIPT REQUIRED) 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 and physiology, medical terminology, basic ICD diagnostic/procedural, & 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 US Department of Education accreditor, or comparable international accrediting authority at the time the program was completed (TRANSCIPT REQUIRED) OR Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements (TRANSCIPT REQUIRED) 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). Grade Determinations:
GS-04 (a)Experience or Education. None beyond the basic requirements GS-05 (a)Experience. One year of creditable experience equivalent to the next lower grade level; OR, (b)Education. Successful completion of a bachelor's degree from an accredited college or university recognized by the US 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. (c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(1)Ability to use health information technology & various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding & abstracting software, etc.). (2)Ability to navigate through & abstract pertinent information from health records. (3)Knowledge of the ICD CM, PCS Official Conventions & Guidelines for Coding and Reporting, and CPT guidelines. (4)Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient & 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 & coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-06 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)Demonstrated Knowledge, Skills, and 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 & 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 apply laws/regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, & HIPAA). (4)Ability to accurately apply the ICD CM, PCS Official Conventions & Guidelines for Coding & Reporting, &CPT Guidelines to various coding scenarios. (5)Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, & skill in applying classifications to both inpatient/outpatient records based on health record documentation. (6)Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) & POA indicators to obtain correct MS-DRG. GS-07 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, 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. (5)Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG. GS-08 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)Demonstrated Knowledge, Skills, and 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 in completing assignments using incomplete or inadequate guidelines. References:
VA Handbook 5005/122 Part II Appendix G57The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08 Physical Requirements:
The work is primarily in a sedentary manner. However, there will be some walking, bending, reaching, stopping, lifting, carrying, and pushing medical records or books. There will be extensive physical demand of constant typing on a keyboard on a PC.
Estimated Salary: $20 to $28 per hour based on qualifications.
Navigate through health records to find needed information to assign codes to encounters (inpatient or outpatient) for the specialty and subspecialty health care services Select and assign codes from the current version of one of more coding system (ICD---CM, CPT, HCPCS) Apply laws and regulations on the confidentiality of health information Ensure that the provider documentation is complete and support the correct sequencing of diagnosis and procedures coded Analyze the medical record to identify all pertinent diagnosis and procedure for coding and to evaluate the adequacy of the documentation Conduct re-review of ICD-10 codes to determine if based on the documentation the specific VERA coding requirements were followed Review and code inpatient professional fee services for identified inpatient admissions for Non-VA Care Establish the primary and secondary diagnosis and procedure codes for billable outpatient encounters Code all surgery procedures in the surgical package in Nuance, ensure all procedures file to the appropriate Patient Care Encounter (PCE), and add Anesthesia and Pathology codes ot the PCE encounter Update codes for current inpatient Long-Term Care and Contract Nursing Home admissions Perform other related duties as assigned Work Schedule:
Full-Time, Monday - Friday, Day Shift Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement. 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-675 series 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 Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure & format of health records. OR Education. 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 and physiology, medical coding, & introduction to health records) (TRANSCIPT REQUIRED) 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 and physiology, medical terminology, basic ICD diagnostic/procedural, & 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 US Department of Education accreditor, or comparable international accrediting authority at the time the program was completed (TRANSCIPT REQUIRED) OR Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements (TRANSCIPT REQUIRED) 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). Grade Determinations:
GS-04 (a)Experience or Education. None beyond the basic requirements GS-05 (a)Experience. One year of creditable experience equivalent to the next lower grade level; OR, (b)Education. Successful completion of a bachelor's degree from an accredited college or university recognized by the US 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. (c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(1)Ability to use health information technology & various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding & abstracting software, etc.). (2)Ability to navigate through & abstract pertinent information from health records. (3)Knowledge of the ICD CM, PCS Official Conventions & Guidelines for Coding and Reporting, and CPT guidelines. (4)Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient & 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 & coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-06 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)Demonstrated Knowledge, Skills, and 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 & 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 apply laws/regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, & HIPAA). (4)Ability to accurately apply the ICD CM, PCS Official Conventions & Guidelines for Coding & Reporting, &CPT Guidelines to various coding scenarios. (5)Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, & skill in applying classifications to both inpatient/outpatient records based on health record documentation. (6)Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) & POA indicators to obtain correct MS-DRG. GS-07 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, 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. (5)Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG. GS-08 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)Demonstrated Knowledge, Skills, and 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 in completing assignments using incomplete or inadequate guidelines. References:
VA Handbook 5005/122 Part II Appendix G57The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08 Physical Requirements:
The work is primarily in a sedentary manner. However, there will be some walking, bending, reaching, stopping, lifting, carrying, and pushing medical records or books. There will be extensive physical demand of constant typing on a keyboard on a PC.
- Department:
0675 Medical Records Technician - Salary Range:
$34,750 to $69,336 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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