Medical Records Technician (Coder)

01Basic Requirements

United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English. Certification.

MRT (Coder) GS-0675 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 and Education. (1)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, (2)Education.

See education section for specific educational requirements; OR (3)Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year. See education section for additional information.; OR, (4)Experience/Education Combination. See education section for specific educational requirements.

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 and meet the criteria).

02Grade Determinations

In addition to the basic requirements, the below qualification requirements must be met at the grade(s) in which you are applying. Medical Records Technician (Coder-Inpatient/Outpatient), GS-4 (a)Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Inpatient/Outpatient).GS-5 (a)Experience. One year of creditable experience equivalent to the next lower grade; OR, (b)Education.

Successful completion of a bachelor's degree, 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, (c)Demonstrated Knowledge, Skills, and Abilities. Must demonstrate all of the following KSAs: 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.).

Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to Inpatient/Outpatient 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 to complete duties within required timeframes and the ability to follow-up on pending issues. Medical Records Technician (Coder-Inpatient/Outpatient), GS-6 (a)Experience. One year of creditable experience equivalent to the next lower grade. AND, (b)Demonstrated Knowledge, Skills, and Abilities.

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. 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. Ability to apply laws and regulations on the confidentiality of health information(e.g., Privacy Act, Freedom of Information Act, and HIPAA). Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.

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/outpatient 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). Medical Records Technician (Coder-Inpatient/Outpatient), GS-7 (a)Experience.

One year of creditable experience equivalent to the next lower grade. AND, (b)Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of inpatient/outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.

Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

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 Medical Records Technician (Coder-Inpatient/Outpatient), GS-8 (a)Experience. One year of creditable experience equivalent to the next lower grade level. AND, (b)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 inpatient/outpatient 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.

Ability to accurately perform the full scope of inpatient/outpatient coding, including inpatient/outpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient/outpatient professional services. 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.

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. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

03Physical Requirements

The work is primarily sedentary. There is walking, bending and reaching required such as for filing or locating material, and carrying items such as reports, documents, and supplies. Entering data and word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain.

The Medical Records Technician (Coder-Inpatient/Outpatient) is located in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center. Medical Records Technicians (Coder-Inpatient/Outpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

To perform this task, they must possess expertise in International Classification of Disease(ICD), Current Procedural Terminology(CPT) and the Healthcare Common Procedure Coding System (HCPCS). Duties Include but are not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient/outpatient facility and/or professional services.

Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of Inpatient/Outpatient settings and specialties. 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.

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/outpatient professional services. 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.

Ensure audit findings have been corrected and refiled. 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. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Work Schedule: Monday - Friday 8:00am - 4:30pm Compressed/Flexible: Not authorized.

Telework: Available Functional Statement #: 10482F, 10483F, 10484F, 10485F, 10486F Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. PCS Appraised Value Offer (AVO): Not authorized.