Medical Records Technician (Coder-Outpatient and Inpatient)

US-Department-of-Veterans-Affair; Tulsa (OK); On-site; USD 42,000 - 64,000; Full time

Job summary

The Eastern Oklahoma VA Healthcare System is seeking a Medical Records Technician (Coder) to classify medical data from patient health records in hospital settings.

Initial requirements include citizenship considerations, one year of creditable experience or an associate degree in health information management, and AHIMA/AAPC coding certification eligibility. The position offers a path through GS-04 to GS-08 and requires adherence to coding guidelines and confidentiality.

Qualifications

• One year of creditable experience in medical terminology and health records.
• An associate's degree with 12+ semester hours in health information management or related field.
• Completion of AHIMA/AAPC coding program leading to certification eligibility.
• Experience/education combinations qualify for the role.

Responsibilities

• Analyze health records to identify diagnoses and procedures for coding.
• Apply ICD-CM, PCS, CPT guidelines to determine correct codes.
• Maintain confidentiality and adhere to HIPAA and related regs.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health information management

Education

Associate’s degree in HIM or related field

AHIMA/AAPC coding program completion

Tools

Electronic health record systems

Coding software

HIPAA/compliance systems

Job description

This position is located in the Health Information Management (HIM) section at the Eastern Oklahoma VA Healthcare System. 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 centers.

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.

Complete all application requirements detailed in the "Required Documents" section of this announcement.

Basic Requirements

• Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Experience and Education:
  • 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.
• Certification. Must have either (1), (2), or (3) below:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Grade Determinations

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

Medical Records Technician, GS-4

• Experience or Education. None beyond basic requirements.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-5

• Experience. One year of creditable experience equivalent to the next lower grade level; OR,
• Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • 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.).
  • Ability to navigate through and abstract pertinent information from health records.
  • Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
  • Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
  • Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
  • Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-6

• Experience. One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
  • Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
  • Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
  • Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
  • Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
  • Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-7

• Experience. One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
  • Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
  • Ability to research and solve coding and documentation related issues.
  • Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
  • Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-8

• Experience. One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
  • Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  • Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Reference

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

The full performance level of this vacancy is GS-08. The 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