Medical Records Technician (Coder-Outpatient and Inpatient)

Veterans Health Administration; Texas; On-site; USD 48,000 - 70,000; Full time

Job summary

Veterans Health Administration is seeking a MRT (Coder) in the Health Information Management section of the Central Alabama Veterans Health Care System. The coder will classify medical data from patient health records in hospital and physician-based settings, ensuring accurate ICD-CM, PCS and CPT coding.

Qualifications include 1 year of related experience or an associate degree with HIM/health information management coursework or AHIMA/AAPC coding program completion.

Qualifications

• 1 year of creditable experience or education in medical terminology, anatomy, physiology, and medical coding.
• Education: Associate's degree with HIM/health information management focus or related degree with 12+ semester hours in HIM/health IT.
• Completion of an AHIMA/AAPC coding program leading to eligibility for coding certification.
• Experience/education combinations allowed; includes military training substitutions with relevant coursework.

Responsibilities

• Classify and abstract medical data from health records for inpatient and outpatient care.
• Apply ICD-CM, PCS, CPT guidelines to code diagnoses and procedures accurately.
• Ensure health record documentation supports coding and regulatory compliance.

Education

Associate's degree in health information technology/health information management

AHIMA/AAPC coding certification preparation or completion

Experience/education combinations in medical terminology and coding

Tools

AHIMA/AAPC certification programs

Job description

This position is located in the Health Information Management (HIM) section at the Central Alabama Veterans Health Care System (CAVHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty center.

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.

English Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Experience or Education: 1year 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 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; ~OR~ Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. Training program must have led to eligibility for coding certification/certification examination, and sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at time the program was completed;~OR~ Experience/Education Combination. Equivalent combinations of creditable experience & education are qualifying for meeting basic requirements. Following educational/training substitutions are appropriate for combining education and creditable experience:(a) 6months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and health record, and 1year 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 Armed Forces or U.S. Maritime Service, under close medical & professional supervision, may be substituted on a month-for-month basis for up to 6months of experience provided training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 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 VHA 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.

Grade Determinations

MRT (Coder-Outpatient and Inpatient): GS-4 Experience or Education. None beyond basic requirements. GS-5 1year of creditable experience equivalent to next lower grade level; OR, (b) Education. Successful completion of 4years of education above high school leading to a bachelor's degree from an accredited college or university recognized by U.S. Dept of Education, 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. KSAs In addition to experience above, and demonstrate all of the following KSAs:

• i. 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.).
• ii. Ability to navigate through and abstract pertinent information from health records.
• iii. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, & CPT guidelines.
• iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient & outpatient episodes of care based on health record documentation.
• v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
• vi. Ability to manage priorities & coordinate work to complete duties within required timeframes, & ability to follow-up on pending issues.

GS-6 1year of creditable experience equivalent to next lower grade level. KSAs In addition to experience above, must demonstrate all of following KSAs:

• i. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding and to evaluate adequacy of documentation.
• ii. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, & support assigned codes. This includes ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
• iii. Ability to apply laws and regulations on confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
• iv. Ability to accurately apply ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, & CPT Guidelines to various coding scenarios.
• v. Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient & outpatient records based on health record documentation.
• vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7 1year of creditable experience equivalent to next lower grade level. KSAs. In addition to experience above, demonstrate all of following KSAs:

• i. 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 health record.
• ii. Ability to communicate with clinical staff for specific coding & documentation issues, such as recording inpatient & outpatient diagnoses & procedures, correct sequencing of diagnoses and/or procedures, and relationship between health record documentation & code assignment.
• iii. Ability to research & solve coding & documentation related issues.
• iv. Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete.
• v. Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct MS-DRG.

GS-8 1year of creditable experience equivalent to the next lower grade level. KSAs In addition to the experience above, demonstrate all of following KSAs:

• i. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding & to evaluate adequacy of documentation. This includes ability to read & understand content of health record, terminology, significance of comments, & disease process/pathophysiology of patient.
• ii. Ability to accurately perform full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, & outpatient encounters, & inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services.
• iii. Skill in interpreting & adapting health information guidelines that are not completely applicable to work, or have gaps in specificity, and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Reference: Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Current VHA employees in this occupation who meet the criteria may qualify under Grandfathering Provision described in VA Qualification Standards.

Full performance level of this vacancy is GS-08. Actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08.

Physical Requirements: See VA Handbook 5019.