Medical Records Technician (Coder Outpatient and Inpatient)

Job Title Journey Level Medical Records Technician (Coder-Inpatient) Job Description The journey level Medical Records Technician (Coder-Inpatient) position incumbent selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, and/or Current Procedural Terminology (CPT) and Health Common Procedure Coding System (HCPCS) classification systems for inpatient facility and/or professional services. Major duties includes and responsibilities included but not limited to: 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. Independently reviews and abstracts clinical data from the record for documentation of diagnosis and procedures to ensure it is adequate and appropriate to support the assigned codes. Codes all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Abstracts, assigns, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Reviews provider health record documentation to ensure that is supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Enters and corrects information that has been rejected and when necessary, the incumbent will correct any identified data errors or inconsistencies. Ensures audit findings have been corrected and refiled. Assigns codes to documented patient care encounters (inpatient facility and/or professional services covering the full range of health care services provided by the VAMC. 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. Uses various computer applications to abstract records, assign codes, and record and transmit data. Work Schedule: 7:00AM- 6:00PM, Monday-Friday Telework: Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized #J-18808-Ljbffr US Department of Veterans Affairs