Med Rec Tech (Med Coder)

SummaryThis position is located in the Health Information Management (HIM) section at the William S. Middleton Memorial VA Hospital. 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.QualificationsApplicants 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 RequirementsUnited States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA PolicyProficient in spoken and written English a) ExperienceOne year of creditable experience equivalent to the next lower gradelevelb) CertificationPersons hired or reassigned to MRT (Coder) positions in the GS-0675series 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 orACDISc) Loss of CredentialFollowing initial certification - credentials must be maintainedthrough rigorous continuing education - ensuring the highest level of competency foremployers and consumersAn employee in this occupation who fails to maintain therequired certification must be removed from the occupation - which may result intermination of employmentGS-0675-04: (a) Experience or EducationNone beyond basic requirements(b) AssignmentEmployees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder)They select and assign codes from current versions of ICD CM - PCS - CPT - and HCPCS classification systems to both inpatient and outpatient recordsThey 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 use various computer applications to abstract records - assign codes - and record and transmit dataThey ensure audit findings have been corrected and refiledMRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unitGS-0675-05: (a) ExperienceOne year of creditable experience equivalent to the next lower grade levelOR - (b) EducationSuccessful 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(c) AssignmentEmployees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding proceduresSelects and assigns codes from current versions of ICD CM - PCS - CPT - and HCPCS classification systems to both inpatient and outpatient recordsThey review record documentation to abstract all required medical - surgical - ancillary - demographic - social - and administrative data - and query clinical staff - as appropriate - with guidance from higher level MRTs (Coder)They use various computer applications to abstract records - assign codes - and record and transmit dataThey ensure audit findings have been corrected and refiledMRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unit(d) Demonstrated 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 - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines16 ivAbility 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 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 issuesGS-0675-06: (a) ExperienceOne year of creditable experience equivalent to the next lower grade level(b) AssignmentEmployees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoringMRTs (Coder) perform a combination of inpatient and outpatient coding dutiesThey select and assign codes from current versions of ICD CM - PCS - CPT - and HCPCS classification systems to both inpatient and outpatient recordsThey review record documentation to abstract all required medical - surgical - ancillary - demographic - social - and administrative data - and query clinical staff - as appropriate - with limited guidance from higher level MRTs (Coder)They use various computer applications to abstract records - assign codes - and record and transmit dataThey ensure audit findings have been corrected and refiledMRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unit(c) Demonstrated 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 - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT Guidelines to various coding scenariosvComprehensive knowledge of current classification systems - such as ICD CM - PCS - CPT - HCPCS - and skill in applying classifications to both inpatient and outpatient records based on health record documentation17 viKnowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRGGS-0675-07: (a) ExperienceOne year of creditable experience equivalent to the next lower grade level(b) AssignmentEmployees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoringMRTs (Coder) perform a combination of inpatient and outpatient coding dutiesSelects and assigns codes from current versions of ICD CM - PCS - CPT - and HCPCS classification systems to both inpatient and outpatient recordsThey review record documentation to abstract all required medical - surgical - ancillary - demographic - social - and administrative data with minimal guidance from higher level MRTs (Coder)They 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 codesThey review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclatureThey also query clinical staff with documentation requirements to support the coding processThey use various computer applications to abstract records - assign codes - and record and transmit dataThey ensure audit findings have been corrected and refiledMRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unit.DutiesDUTIES: Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMCPatient encounters are often complicated and complex requiring extensive coding expertiseApplies 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 Evaluation and Management code to ensure ethical - accurate - and complete codingAlso applies codes based on guidelines specific to certain diagnoses - procedures - and other criteria (in inpatient and outpatient settings) 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 needsMonitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMCTimely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programsPerforms a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capturePatient health records may be paper or electronicThe 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 programsAssists 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 sequencingInsures provider documentation is complete and supports the diagnoses and procedures codedDirectly consults with the professional staff for clarification of conflicting or ambiguous clinical dataReports incorrect documentation or codes in the electronic patient health recordExpertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient recordUtilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA database in AustinCorrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelinesIndependently researches references to resolve any questionable code errorscontacts supervisor as appropriateUses a variety of computer applications in day-to-day activities and duties - such as Outlook - Excel - Word - and Accesscompetent in use of the health record applications (VistA and CPRS) as well as the encoder product suiteOrients and instructs new personnel and/or students from affiliated health information or medical record technology programs - at the direction of the supervisor - on unit operations - coding - abstracting - and use of an electronic health recordWorks within a team environmentsupports peers in meeting goals and deadlinesflexible and handles multiple tasksworks under pressureand copes with frequently changing projects and deadlinesWork Schedule: 8:00am-4:30pm Virtual: This position is 100% remote Functional Statement #: 09671F - 09672F - 09673F - 09674F.