Medical Records Technician (CDIS - Inpatient)

Summary MRTs (CDIS - Inpatient) 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. Summary MRTs (CDIS - Inpatient) 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. Qualifications 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 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 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 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: In addition to the above experience - the flowing needs to be met Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)) - GS-9 Experience One year of creditable experience equivalent to the journey grade level of a MRT (Coder-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 Note: Mastery Level Certification This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC To be acceptable for qualifications - the specific certification must represent a comprehensive competency in the occupation Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies However - 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) OR - Clinical experience such as RN - M.D. - or DO - and one year of experience in clinical documentation improvement Certification Employees at this level must have either a mastery level certification or a clinical documentation improvement certification Mastery Level Certification This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC To be acceptable for qualifications - the specific certification must represent a comprehensive competency in the occupation Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies However - 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) Clinical Documentation Improvement Certification This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS) To be acceptable for qualifications - the specific certification must certify mastery in clinical documentation Certification titles may change - and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies However - current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist Qualifications continue in the Education section. Duties Total Rewards of a Allied Health Professional Duties of the Medical Records Technician (CDIS-Inpatient) include - but are not limited to: Demonstrates expertise in International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS) MRT (Coder) may also provide education related to coding and documentation Reviews the overall quality and completeness of clinical documentation Health records are reviewed either concurrently or retrospectively for ambiguous - conflicting - incomplete - or nonspecific provider documentation Collaborates with clinical staff through written - verbal - or electronic clarification requests or queries Reviews clinical documentation and provides education to clinical staff on outpatient episodes of care Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding - workload - quality measures - reimbursement - and funding Provides education to providers on the need for accurate and complete documentation in the health record - appropriate code selection of Evaluation and Management (E/M) - Current Procedural Terminology (CPT) and ICD-10 diagnosis codes - and ensuring documentation supports the codes selected to the highest degree of specificity Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided Consults with the professional staff for clarification of conflicting or ambiguous clinical data Adheres to accepted coding practices - guidelines - and conventions when verifying the most appropriate diagnosis - operation - procedure - ancillary - or E/M code to ensure ethical - accurate - and complete coding Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator Develops and conducts seminars - workshops - short courses - informational briefings - and conferences concerned with health record documentation - educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff Facilitates improved overall quality - completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians - other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate Participates in clinical rounds and may - where appropriate - offer information on documentation - coding rules and reimbursement issues Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management Work Schedule: Monday - Friday - 8:00 am to 4:30 pm - subject to change based on the needs of the facility Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases 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 (Above Minimum Rate of the Grade) 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) Remote: The position is remote work eligible and is exempted from returned to office requirements Remote exempted positions are reviewed annually and do not imply permanent remote work status Functional Statement #: 598-01373F Permanent Change of Station (PCS): Not Authorized #J-18808-Ljbffr U.S. Department of Veterans Affairs