Medical Records Technician (CDIS) Inpatient/Outpatient

This position is located in the Health Information Management section at the Fayetteville NC VA Coastal Health Care 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

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 (1) 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, (2) 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, (3) 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, (4) 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:(a) Six months of creditable experience that indicates knowledge of medical. 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). GS-09 Grade Determinations:(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (GS-08) (Coder-Outpatient and Inpatient); OR, An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. (b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. 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). Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP)Certified Clinical Documentation Specialist (CCDS). GS-09 Experience CDISs must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient). CDISs serve as the liaison between health information management and clinical staff. They are responsible for facilitating improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. They recommend changes and/or update medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. They review health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines and regulations. Preferred Experience: Extensive knowledge of coding rules and regulations, to include: current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. Must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure and POA indicators. (d) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii. Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record, including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. iv. Ability to establish and maintain strong verbal and written communication with providers v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.vii. Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients. viii. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. References: VA Handbook 5005/122, Part II, Appendix G57 Medical Records Technician (Coder) GS-0675; Dated December 10, 2019. Physical Requirements: Light lifting, under 15 lbs., moderate carrying, 15-44 lbs., reaching above shoulder, use of fingers, standing 4-6 hours; hearing, aid permitted. Duties require extensive use of fingers to perform keyboarding and the ability to hear requests by phone and in person. Vision must be adequate to read and prepare documents.