Medical Records Technician (Inpatient Coder)

US-Department-of-Veterans-Affair; Salisbury (NC); Hybrid; USD 45,000 - 75,000; Full time

Job summary

The U.S. Department of Veterans Affairs is hiring a Medical Records Technician (Coder-Inpatient) to support inpatient coding and health information management. The position encompasses applying ICD-CM/PCS coding conventions, abstracting health record data, and ensuring documentation supports accurate MS-DRG assignments.

Candidates may qualify at GS-5 through GS-8 with relevant experience or education, and must meet the basic requirements, including U.S. citizenship and English proficiency.

Qualifications

• One year of creditable experience with medical terminology and health records.
• Associate degree with HIM/HIT major or related study including 12+ semester hours in HIM/IT.
• AHIMA or coding program leading to certification eligibility.
• Experience/education combinations qualify.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health information management

ICD-CM/PCS coding

Abstract health records

Health information technology

Documentation guidelines knowledge

Prioritization & time management

Education

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

AHIMA or AAPC coding program

Bachelor's degree with 24 credit hours in HIM/IT

Job description

This position is eligible for remote work and is currently operating under an extension of the Return-to-Office (RTO) mandate. Please note that remote work eligibility is reviewed on an ongoing basis and does not imply a permanent remote work status until an exemption is approved. Employees in this role may be required to comply with future RTO requirements as determined by agency policy.

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;
  • Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA 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.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations

Medical Records Technician (Coder-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:
  • 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 and PCS Official Conventions and Guidelines for Coding and Reporting.
  • iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation.
  • v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
  • vi. 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-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:
  • i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the 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, 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.
  • iii. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
  • iv. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
  • v. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation.
  • vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).

Medical Records Technician (Coder-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:
  • i. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
  • ii. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
  • iii. Ability to research and solve coding and documentation related issues.
  • iv. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
  • v. 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-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:
  • i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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, and the significance of the comments, and the disease process/pathophysiology of the patient.
  • ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  • iii. 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-4. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

Physical Requirements

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