Medical Records Technician (Coder- Inpatient/Outpatient)

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 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. ]]]]>