Medical Records Technician (Coder-Inpatient)

Summary
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.
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
• 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 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
• (b) 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: (1) Apprentice/Associate Level Certification through AHIMA or AAPC
• (2) Mastery Level Certification through AHIMA or AAPC
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS
• English Language Proficiency
• MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• Medical Records Technician (MRT) (Coder-Inpatient) GS-4 (a) Experience or Education
• None beyond basic requirements
• 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
• (d) Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: i
• 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.)
• ii
• Ability to navigate through and abstract pertinent information from health records
• iii
• Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting
• iv
• Ability to apply knowledge of medical terminology - human anatomy/physiology - and disease processes to accurately assign codes to inpatient records based on health record documentation
• v
• Knowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelines
• vi
• Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues
• GS-6 Experience
• One year of creditable experience equivalent to the next lower grade level
• KSA's
• 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 coding and to evaluate the adequacy of the documentation
• ii
• Ability to determine whether health records contain sufficient information for regulatory requirements - are acceptable as legal documents - are adequate for continuity of patient care - and support the assigned codes
• This includes the ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliable
• iii
• Ability to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and HIPAA)
• iv
• Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios
• v
• Comprehensive knowledge of current classification systems - such as ICD Clinical Modification (CM) and PCS - CPT - and HCPCS - and skill in applying said classifications to inpatient records based on health record documentation
• vi
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) - and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG)
• (4) MRT Coder-Inpatient GS-7 Experience
• One year of creditable experience equivalent to the next lower grade level
• KSA's
• In addition - the candidate must demonstrate all of the following KSAs as explained in the VA Qualification Standards: i
• Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record
• ii
• Ability to communicate with clinical staff for specific coding and documentation issues - such as recording diagnoses and procedures - the correct sequencing of diagnoses and/or procedures - and the relationship between health record documentation and code assignment
• iii
• Ability to research and solve coding and documentation related issues
• iv
• Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
• v
• Ability to abstract - assign - and sequence codes - including complication or comorbidity/major complication or comorbidity (CC/MCC) - and POA indicators - to obtain correct MS-DRG
• (5) MRT Coder-Inpatient GS-8 Experience
• One year of creditable experience equivalent to the next lower grade level
• KSA's
• In addition - the candidate must demonstrate all of the following KSAs as explained in the VA Qualification Standards: 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.
  

Duties

• Duties include but are not limited to: Applies knowledge of medical record content - medical terminology - anatomy & physiology - diseases processes - and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and/or Healthcare Common Procedure Coding System (HCPCS)
• With instruction from a senior coder or supervisor learns to select diagnosis - operation - or procedure codes based on the accepted coding practices - guidelines - conventions - and policy
• Reviews record documentation to abstract all required medical - surgical - ancillary - demographic - social - and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record
• Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance
• Utilizes the facility computer system and software applications to code - abstract - record - and transmit data to the national VA database in Austin
• Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed
• Uses a variety of computer applications in day to day activities and duties - such as Outlook - Excel - Word - and Access
• develops use of the health record applications (VistA and CPRS) as well as the encoder product suite
• Work Schedule: Monday-Friday - 07:30am-04:00pm Compressed/Flexible: Not Available Telework: Not Available Virtual: This is not a virtual position
• Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized 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.

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