Medical Records Technician (Coder In/Out)

US Department of Veterans Affairs; Austin (TX); On-site; USD 65,000 - 85,000; Full time

Job summary

US Department of Veterans Affairs in Austin, TX is seeking a Coding Specialist to assign and review codes for inpatient and outpatient care across the VA health system. The role requires proficiency with ICD, CPT, HCPCS and VA-specific systems such as VistA/CPRS.

The position emphasizes accurate coding, adherence to regulatory guidelines, and collaboration with clinical and administrative staff to ensure complete documentation and proper reimbursement.

Responsibilities

• Assigns codes to documented patient care encounters (inpatient and outpatient) across VA services.
• Selects and assigns ICD, CPT, and HCPCS codes from current code sets.
• Adheres to coding guidelines to ensure ethical, accurate coding.
• Monitors regulatory changes affecting coded information across the facility.
• Reviews medical records to abstract data for complete capture.
• Provides guidance to staff on documentation and coding requirements.
• Uses VistA/CPRS and encoder tools to code and transmit data to VA databases.
• Orients new personnel on unit operations, coding, and EHR use.

Job description

Job Title

Coding Specialist

Duties

Duties and responsibilities of this position include, but are not limited to the following: Basic Functions

• Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the FHCC.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the FHCC.
• Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.

Specific Functions

• Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) 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.
• Codes inpatient professional fee services for identified inpatient admissions.
• 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 Evaluation & Management service provided.
• 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.
• Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay admissions to reflect all patient conditions and care up to the census date or to the requested billing date.
• Reviews and codes assigned fee service Care in the Community patient encounters (inpatient and outpatient) using the paper or electronic documentation obtained from non-VA facilities.
• Codes diagnoses from paper forms for VA registries.

Work Schedule: Monday-Friday, 8:00am - 4:30pm

Telework: Not Authorized

Virtual: This is not a virtual position

Functional Statement #: 02623F

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

Financial Disclosure Report: Not required