Medical Records Technician (Coder Outpatient and Inpatient)

US Department of Veterans Affairs; San Diego (CA); Hybrid; USD 40,000 - 65,000; Full time

Job summary

The Journey Level Medical Records Technician (Coder-Inpatient) at the US Department of Veterans Affairs performs coding for inpatient facility and professional services using ICD-10-CM, ICD-10-PCS, CPT/HCPCS, and HCPCS classification systems. The role includes reviewing documentation, abstracting clinical data, and ensuring accurate DRG-related coding.

Flexibility includes telework with a standard daytime schedule, and duties require collaboration with clinical staff to resolve ambiguities while

Qualifications

• Proficient in selecting and assigning ICD-10-CM/PCS and CPT/HCPCS codes.
• Ability to review health records to support accurate coding for DRG assignment.
• Experience abstracting data and using encoder software to reflect services rendered.
• Communicates with clinical staff to clarify conflicting or incomplete data.

Responsibilities

• Code inpatient facility and professional services to reflect DRGs accurately.
• Abstract and sequence codes using encoder software.
• Review provider documentation to ensure codes reflect services rendered.
• Consult with clinicians to resolve ambiguities in coding data.
• Enter and correct information for rejected records and audit findings.

Skills

ICD-10-CM

ICD-10-PCS

CPT/HCPCS

Medical terminology

Anatomy & physiology

DRG knowledge

Tools

Encoder software

Health IT systems

Job description

Job Title

Journey Level Medical Records Technician (Coder-Inpatient)

Job Description

The journey level Medical Records Technician (Coder-Inpatient) position incumbent selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, and/or Current Procedural Terminology (CPT) and Health Common Procedure Coding System (HCPCS) classification systems for inpatient facility and/or professional services. Major duties includes and responsibilities included but not limited to:

• Performance of a 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 professional services.
• Independently reviews and abstracts clinical data from the record for documentation of diagnosis and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Codes all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties.
• Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstracts, assigns, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Reviews provider health record documentation to ensure that is supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Enters and corrects information that has been rejected and when necessary, the incumbent will correct any identified data errors or inconsistencies.
• Ensures audit findings have been corrected and refiled.
• Assigns codes to documented patient care encounters (inpatient facility and/or professional services covering the full range of health care services provided by the VAMC.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes treatment modalities, diagnostic tests, medications procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Uses various computer applications to abstract records, assign codes, and record and transmit data.

Work Schedule: 7:00AM- 6:00PM, Monday-Friday

Telework: Available

Virtual: This is not a virtual position.

Functional Statement #: 000000

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized