Medical Records Technician -Coder-Outpatient and Inpatient

U.S. Department of Veterans Affairs; West Palm Beach (FL); On-site; USD 50,000 - 70,000; Full time

Job summary

A leading company seeks an MRT (Coder) at the West Palm Beach VA Medical Center. This role involves classifying and coding medical records. Candidates should have relevant experience or education in health information management and applicable certifications. Join to contribute to veterans' healthcare with a comprehensive coding process.

Qualifications

• One year experience in medical terminology, anatomy, physiology, and medical coding.
• Eligible for coding certification through AHIMA or AAPC.
• Proficient in English.

Responsibilities

• Classifying medical data from health records.
• Abstracting clinical data for accurate coding.
• Applying current coding classifications to inpatient and outpatient records.

Skills

Medical terminology

Anatomy

Physiology

Medical coding

Education

Associate's degree in health information technology

Completion of AHIMA approved coding program

Job description

This position is located in the Health Information Management (HIM) section at the West Palm Beach VA Medical Center. 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. These coding practitioners analyze and abstract patients. health records and assign alphanumeric codes for each diagnosis and procedure.
Duties

Requirements

Qualifications
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.

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. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

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. The following educational/training substitutions are appropriate for combining education and creditable experience:
  • Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.
  • Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Please select the proper response for your experience and/or education.

Certification Requirements-Documentation Submitted. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:

• Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Current Apprentice/Associate level certifications include Certified Coding Associate (CCA), Certified Professional Coder-Apprentice (CPC-A) and Certified Outpatient Coding- Apprentice (COC-A).
• Mastery Level Certification through AHIMA or AAPC.
  • Current mastery level certifications include Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • Current Clinical Documentation Improvement Certifications include Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.

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

Experience. One year of creditable experience equivalent to the next lower grade level, GS-07. The knowledge, skills, and abilities at the GS-07 grade level include the following:

• 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.

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.

Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Continue assignment by reviewing qualification standard listed below.

Preferred Experience: Minimum of one year experience with Inpatient Coding.

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.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.