Medical Records Technician (Coder- Inpatient/Outpatient)
What you'd do
This position is located in the Health Information Management (HIM) section at the Orlando 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.
Major duties
Duties Include:: Assigns codes to documented patient care encounters (Inpatient /Outpatient facility and/or professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate. Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and procedure codes are selected from the current version of the ICD coding system. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Work Schedule: Monday-Friday, 8am to 4:30pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA. Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Available, This position is telework eligible and exempted from return to office requirements. This position will be reviewed annually and does not imply permanent telework status. Current employees will be granted an exception to remain in the current duty station location if outside VISN 8. Virtual: This is not a virtual position. Functional Statement #: 82470F, 80539F, 80133F, 80134F, 80135F Permanent Change of Station (PCS): Not Authorized
What you need to qualify
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 4 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). 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. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8. Grade Determinations: Medical Records Technician (Coder-In/Outpatient), GS-4 Experience or Education. None beyond basic requirements. Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM and the PCS, and/or, CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder). They also use various computer applications to abstract records, assign 11 codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. 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. Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. 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. 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. ***Please see additional grade level requirements under Education section.***
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