Medical Records Technician (Coder - Inpatient)

US Department of Veterans Affairs; Lexington (KY); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Telework available

Federal pension

Paid holidays

Job summary

US Department of Veterans Affairs in Lexington, KY seeks an Allied Health Professional to code inpatient and professional encounters using ICD-10-CM/PCS, CPT, and HCPCS in our facilities. You will review records to abstract data and ensure accurate coding under supervision.

Role involves applying guidelines, learning to link diagnoses with procedures, and using health record systems to transmit data to the VA database.

Responsibilities

• Selecting and assigning codes from ICD/CM/PCS for inpatient MS-DRG coding, CPT, and HCPCS for inpatient professional coding.
• Learn to select diagnosis, operation, or procedure codes based on accepted guidelines and policy.
• Reviewing record documentation to abstract medical, surgical, ancillary, demographic, social, and administrative data.
• Using hospital systems to code, abstract, record, and transmit data to the VA database; identify and correct errors under supervision.
• Maintains knowledge of regulatory and policy requirements affecting coded information.
• Identify principal diagnosis and procedure for inpatient stays and DRG determination.
• Orienting and instructing new personnel on unit operations, coding, and electronic health record use.

Job description

Allied Health Professional

Duties of the position will vary dependent on grade for which selected, but may include:

• Selecting and assigning codes from the current versions of the International Classification of Diseases (ICD), Clinical Modification (CM), and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding.
• Learn to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions, and policy
• Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record
• Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance
• Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin, identified errors are reviewed with a senior coder or the supervisor and corrections made as directed
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; develops use of health record applications as well as the encoder product suite
• Maintains current knowledge of regulatory and policy requirements affecting coded information
• Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment
• Works within a team environment; supporting peers in meeting goals and deadlines, coping with frequently changing projects and deadlines
• Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays
• Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission, codes the admission diagnosis for use by unit staff utilizing the current version of the ICD coding system
• 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
• 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
• Establishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters

Work Schedule: 0600-1800 (Flexible) Monday-Friday

Pay: Competitive salary and regular salary increases.

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.

Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA

Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)

Telework: Available, AD-HOC purposes

Virtual: This is not a virtual position.

Functional Statement #: 30292F | 30291F | 30290F | 30289F | 30288F

Permanent Change of Station (PCS): Not Authorized