Med Rec Tech (Med Coder)

US Department of Veterans Affairs; United States; Remote; USD 55,000 - 75,000; Full time

Job summary

US Department of Veterans Affairs is seeking an outpatient medical coder to review patient records and assign ICD-10 and CPT/HCPCS codes for surgeries, procedures, and visits. The coder ensures documentation supports the codes, corrects errors, and clarifies information with clinical staff.

The role requires coding certification eligibility and familiarity with health information management systems. This is a remote position within the United States.

Qualifications

• Knowledge of medical terminology, anatomy, physiology, and health records.
• Experience with medical coding using ICD, CPT, HCPCS.
• Eligibility or possession of AHIMA/AAPC coding certification.

Responsibilities

• Review patient records and assign ICD-10 and CPT/HCPCS codes for visits and procedures.
• Validate documentation supports codes and correct errors.
• Interface with clinical staff to resolve missing or unclear information.
• Perform audits and drive documentation improvement.

Skills

Medical terminology

Anatomy

Physiology

Medical coding

Health records

Education

Associate's degree in Health Information Technology/Health Information Management

AHIMA/AAPC coding certification eligibility

Coursework in medical terminology, anatomy & physiology, coding

Tools

3M coding system

Electronic Health Record systems

Job description

This position is an outpatient medical coder who reviews patient records and assigns correct ICD-10 and CPT/HCPCS codes for surgeries, procedures, and visits. The coder checks that documentation supports the codes, fixes errors, works with clinical staff to clarify missing or unclear information, and ensures audit issues are corrected. They handle complex cases across many specialties and use various computer systems to enter and manage coding data.

THIS IS A REMOTE POSITION

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.
• 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 VA must have either (1), (2), or (3):

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

NOTE:

Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Assignment:

For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Outpatient CDISs must be able to perform all duties of a MRT (Coder-Outpatient). CDISs serve as the liaison between health information management and clinical staff. They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload, and resource allocations. They review documentation and facilitate modifications to the health record to ensure accurate complexity of care and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and 20 chronic conditions, and reflect the true health status of patients. They recommend changes and/or updates to medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. They are responsible for performing reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate leadership and groups. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. They monitor trends in the industry and/or changes in regulations that could or should impact coding and documentation practices and identify who may require education. 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.)

Grade Determinations

Medical Records Technician Outpatient (Coder) Auditor, GS-09GS-8(Mastery Level) Experience.

One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

1. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).
2. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.
4. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
5. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

Preferred Experience:

Experience performing the duties of a MRT coder in a healthcare setting. Knowledge of current coding classification systems such as ICD, CPT. and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined)Experience reviewing coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. Strong computer skills, particularly with Microsoft Office and Excel applications and other relevant software. Experience with the 3M coding and reimbursement system. Clear and concise communication is necessary to explain findings to physician coders, and other healthcare professionals.

References:

VA Handbook 5005, Part II, Appendix G57, Medical Records Technician Qualification Standards.

The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is GS-8.

Physical Requirements:

Position is sedentary. Duties require extensive use of fingers to perform keyboarding and the ability to hear requests by phone and in person. Vision must be adequate to read and prepare documents.