Medical Records Tech (Coder-Inpatient)

SummaryThis position is located in the Health Information Management Section (HIMS) at the Central Virginia VA Health Care System (CVHCS). 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.QualificationsBasic Requirements:United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA PolicyEnglish Language ProficiencyMRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f) 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 AAPCMastery Level Certification through AHIMA or AAPCClinical Documentation Improvement Certification through AHIMA or ACDIS Experience and Education (1) ExperienceOne year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of a health recordsOR - (2) EducationAn 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 codingThe 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 completedOR - (4) Experience/Education CombinationEquivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsMay 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-4 - None beyond basic requirementsMedical Records Technician (Coder-Inpatient) - GS-5 ExperienceOne year of creditable experience equivalent to the next lower grade levelOREducationSuccessful 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 technologyDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: iAbility 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.)iiAbility to navigate through and abstract pertinent information from health recordsiiiKnowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and ReportingivAbility to apply knowledge of medical terminology - human anatomy/physiology - and disease processes to accurately assign codes to inpatient records based on health record documentationvKnowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelinesviAbility to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issuesMedical Records Technician (Coder-Inpatient) - GS-6 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: iAbility to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentationiiAbility 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 codesThis includes the ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliableiiiAbility to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and HIPAA)ivAbility to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenariosvComprehensive 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 documentationviKnowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) - and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG)Medical Records Technician (Coder-Inpatient) - GS-7 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: iSkill 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 recordiiAbility 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 assignmentiiiAbility to research and solve coding and documentation related issuesivSkill in reviewing and correcting system or processing errors and ensuring all assigned work is completevAbility to abstract - assign - and sequence codes - including complication or comorbidity/major complication or comorbidity (CC/MCC) - and POA indicators - to obtain correct MS-DRGMedical Records Technician (Coder-Inpatient) - GS-8 ExperienceOne year of creditable experience equivalent to the next lower grade levelDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate must demonstrate all of the following KSAs: iAbility to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentationThis 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 patientiiAbility to accurately perform the full scope of inpatient coding - including inpatient discharges - surgical cases - diagnostic studies and procedures - and inpatient professional servicesiiiSkill 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 guidelinesReference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/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. Physical Requirements: The work is primarily sedentaryTypically - the employee may sit comfortably to do the workHowever - there may be some walkingstandingbendingNo special physical demands are required to perform the work.DutiesBasic Functions: Assigns codes to documented inpatient care encounters covering the full range of health care servicesApplies 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 selectionSelects 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 codingApplies 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 needsPerforms a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data captureAssists facility staff with documentation requirements to completely and accurately reflect the patient care providedProvides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencingSpecific Functions: Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient dischargealso identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG)Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followedcorrects coding as needed to ensure proper patient classification in the VERA programCodes inpatient professional fee services for identified inpatient admissionsCode selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursementEstablishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters following applicable regulations - instructions - and requirements for allowable reimbursementlinks the appropriate diagnosis to the procedure and/or determines level of E/M service providedCodes all inpatient procedures reported in the Surgical Package of the VistA hospital systemApplies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suiteEnsures all procedures file to the appropriate Patient Care Encounter (PCE)Reviews and codes assigned fee service Care in the Community inpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals - military facilities - etcOther duties as assignedTotal Rewards of a Allied Health Professional Work Schedule: 8:00 am- 4:30 pmMonday- Friday Pay: Competitive salary and regular salary increasesWhen 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 experienceParental 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 childChild 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 $416.66Retirement: 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) Telework: Available - per agency policy Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized