Medical Records Technician (Coder Inpatient)
What you'd do
Inpatient (Coder) select codes from current versions of ICD CM, PCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG),and/or assigning CPT/HCPCS codes.
Major duties
This job opportunity announcement (JOA) will be used to fill one 1) full-time and permanent Medical Records Technician (Inpatient Coder) vacancy(s) at the Memphis, TN Veteran Affairs Medical Center (VAMC), with Business Office Service. The technician is assigned to the Health Information Management Section (HIMS), coding/analysis unit, VAMC Memphis, TN. Inpatient MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the 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. 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. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They must abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. Work Schedule: Monday - Friday 7:30 a.m. - 4:00 p.m. or 8:00 a.m. - 4:30 p.m. Virtual: This is a virtual position for highly qualified candidate at the full performance, GS-08, level. Position Title/Functional Statement #: 000000 Financial Disclosure Report: Not required.
What you need to qualify
BASIC REQUIREMENTS. (a) United States Citizenship: Must be a U. S. citizen. (b) English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English. (c) Certification. MRT (Coder) GS-0675 must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. Certified Coding Associate (CCA) Certified Professional Coder-Apprentice (CPC-A) Certified Outpatient Coding-Apprentice (COC-A) (2) Mastery Level Certification through AHIMA or AAPC. 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) Certified Coding Specialist (CCS) (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. Clinical Documentation Improvement Practitioner (CDIP) Certified Clinical Documentation Specialist (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding & the structure/format of a health record. ~OR~ (2) Education. An associate's degree from an accredited college/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 & physiology, medical coding & introduction to health records). ~OR~ (3) Completion of an AHIMA approved coding program /other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, the sponsoring academic institution must be accredited by a national U.S. Department of Education accreditor/comparable international accrediting authority at the time the program was completed (4) Experience/Education Combination. Equivalent combinations of creditable experience/education are qualifying for meeting the basic requirements. (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, and one year above high school, with a minimum of 6 semester hours.. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists/hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical professional supervision. GRADE DETERMINATIONS AND ASSIGNMENTS. (1) Medical records Technician (Coder-Inpatients), GS-4 (a) Experience or Education- None beyond basic requirements above. (2) Medical records Technician (Coder-Inpatients), GS-5 (a) Experience. One year creditable experience equivalent to the next lower grade level ~OR~ (b) Education. Successful completion of a bachelor's degree from accredited college or university. (c) (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs: 1. Ability to use health information technology and various office software products used in MRT (Coder) positions. 2. Ability navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and reporting. 4. 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. 5. Knowledge of The Joint Commission requirements CMS and/or health record documentation guidelines. 6. Ability to manage priorities and work to complete duties within the required timeframes and the ability to follow-up on pending issues. (3) Medical records Technician (Coder-Inpatients), GS-6 (a) Experience. One year creditable experience equivalent to the next lower grade level (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2. 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. 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). 4. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. 5. 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. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). (4) Medical records Technician (Coder-Inpatients), GS-7 (a) Experience. One year creditable experience equivalent to the next lower grade level (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs: 1.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. 2.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. 3.Ability to research and solve coding and documentation related issues. 4.Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. 5.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. (5) Medical records Technician (Coder-Inpatients), GS-8 (a) Experience. One year creditable experience equivalent to the next lower grade level (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs: 1.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, the significance of the comments, and the disease process/pathophysiology of the patient. 2.Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. 3.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.. Physical Requirements: The work is primarily sedentary. There is walking, bending & reaching required such as for filing or locating material & carrying items such as reports, documents/supplies.
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