Medical Records Technician (Coder-Inpatient)

Summary This position is located in the Veterans Health Administration (VHA) - Southeast Network (VISN 7) - VA Augusta Health Care System in Augusta - Georgia located in the Health Information Management Section (HIMs) of Health Administration Service (HAS). 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. Summary This position is located in the Veterans Health Administration (VHA) - Southeast Network (VISN 7) - VA Augusta Health Care System in Augusta - Georgia located in the Health Information Management Section (HIMs) of Health Administration Service (HAS). 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. Qualifications Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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 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) (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 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 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: Medical Records Technician (Coder-Inpatient) - GS-8: (a) Experience One year of creditable experience equivalent to the next lower grade level (b) Assignment This is the journey level for this assignment 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 Inpatient duties consist of the 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 They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes They code all complicated and complex medical/specialty diseases processes - patient injuries - and all medical procedures in a wide range of inpatient settings and specialties They directly consult with the clinical staff for clarification of conflicting - incomplete - or ambiguous clinical data in the health record They must abstract - assign - and sequence codes into encoder software to obtain correct DRG - support medical necessity - resolve encoder edits - and ensure codes accurately reflect services rendered They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature They query clinical staff with documentation requirements to support the coding process They also enter and correct information that has been rejected - when necessary They correct any identified data errors or inconsistencies They ensure audit findings have been corrected and refiled They use various computer applications to abstract records - assign codes - and record and transmit data MRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unit AND (c) Demonstrated Knowledge - Skills - and Abilities In addition to the experience above - the candidate must demonstrate all of the following KSAs: i Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation This includes the ability to read and understand the content of the health record - the terminology - the significance of the comments - and the disease process/pathophysiology of the patient ii Ability to accurately perform the full scope of inpatient coding - including inpatient discharges - surgical cases - diagnostic studies and procedures - and inpatient professional services iii Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity - and the ability to use judgment in completing assignments using incomplete or inadequate guidelines Preferred Experience: 1 year or more of VHA GS-0675-08 MRT Coder- Inpatient experience at a 1a/b VHA facility Experience that is not CDIS or billin experience Reference: For more information on this qualification standard - please visit The full performance level of this vacancy is 8 Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service. Duties Basic Functions: 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 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 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 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 Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided provides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencing Ensures provider documentation is complete and supports the diagnoses and procedures coded Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data Reports incorrect documentation or codes in the electronic patient health record Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record Work Schedule: Monday- Friday 7:00am-3:30pm Telework: Remote 100% Outside of Area Virtual: This is a virtual position Functional Statement #: 62321F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized #J-18808-Ljbffr U.S. Department of Veterans Affairs