[Hiring] Inpatient Coder @Palo Alto VA Medical Center

Role Description

The Medical Records Technician (MRT) Coder is responsible for performing a quality review of patient care documents and assigning codes specific to the type of care provided. For this assignment, Inpatient MRTs (Coders) select and assign codes from current versions of ICD-CM, PCS, and/or CPT and HCPCS classification systems for the full scope of inpatient facility and/or professional services.

The duties below are for the GS-0675-08, Journey Level.

• Utilize various computer applications to abstract records and assign codes to documented patient care records.
• 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
  • Procedures for accurate assignment of diagnosis-related groups (DRG)
• Code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of inpatient settings and specialties.
• Has in-depth knowledge of:
  • Medical terminology
  • Anatomy & physiology
  • Diseases
  • Treatments
  • Diagnostic tests
  • Medications to ensure proper code selection.
• Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
• Coding systems include:
  • Current versions of the International Classification of Diseases (ICD)
  • Procedure Coding System (PCS)
  • Healthcare Common Procedure Coding System (HCPCS)
• Adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate:
  • Diagnosis
  • Operation
  • Procedure
  • Ancillary
  • Evaluation and Management code to ensure ethical, accurate, and complete coding.
• Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program.
• Maintains current knowledge of regulatory and policy requirements affecting coded information.
• Independently reviews health record documentation to abstract all required:
  • Medical
  • Surgical
  • Ancillary
  • Demographic, social, and administrative data and queries clinical staff, as appropriate.
• Independently assesses:
  • Basic documentation requirements
  • Coding requirements
  • Accepted nomenclature and proper sequencing to obtain correct DRG
  • Supports medical necessity
  • Resolves encoder edits and ensures codes accurately reflect services rendered.
• Ensures provider documentation supports the diagnoses and procedures coded.
• Utilizes the facility computer system and software applications to:
  • Code
  • Abstract
  • Record and transmit data to the national VA database in Austin
  • Correct any identified data errors, inconsistencies or audit findings in a timely manner.
• Research references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.
• Uses a variety of window-based applications in day-to-day activities and duties, such as:
  • Outlook
  • Excel
  • Word
  • Access
• Competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
• Ensures current versions of all software applications are loaded and functional after any updates or changes.
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Other Duties as assigned.

Qualifications

• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, structure and format of health records.
• OR, 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.
• OR, completion of an AHIMA-approved coding program, or other intensive coding training program of approximately one year or more that included courses in anatomy, physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding.
• OR, equivalent combinations of creditable experience and education qualify for meeting the basic requirements.

Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
  • Apprentice/Associate Level Certification through AHIMA or AAPC
  • Mastery Level Certification through AHIMA or AAPC
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education.
• Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Benefits

• Work Schedule: M-F 8:00 am - 4:30 pm or as determined by the supervisor.
• Compressed/Flexible: This may be authorized at the supervisor's discretion.
• Telework: This is a Remote position.
• Virtual: This is not a virtual position.