[Hiring] Medical Records Technician (Coder) @Clement J Zablocki Veterans Administration Medical Center

Role Description

The Medical Records Technician (Coder-Inpatient/Outpatient) is located in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center. Medical Records Technicians (Coder-Inpatient/Outpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Disease (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

• Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient/outpatient facility and/or professional services.
• Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of Inpatient/Outpatient settings and specialties.
• 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.
• 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/outpatient professional services.
• 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.
• Ensure audit findings have been corrected and refiled.
• 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.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• 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.
• Certification: MRT (Coder) GS-0675 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.
• 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 health records.
  • (2) Education: See education section for specific educational requirements.
  • (3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year.
  • (4) Experience/Education Combination: See education section for specific educational requirements.

Requirements

• Medical Records Technician (Coder-Inpatient/Outpatient), GS-4:
  • (a) Experience or Education: None beyond basic requirements.
• Medical Records Technician (Coder-Inpatient/Outpatient), GS-5:
  • (a) Experience: One year of creditable experience equivalent to the next lower grade.
  • (b) Education: Successful completion of a bachelor's degree, 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) Demonstrated Knowledge, Skills, and Abilities:
    • Ability to use health information technology and various office software products used in MRT (Coder) positions.
    • Ability to navigate through and abstract pertinent information from health records.
    • Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
    • Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to Inpatient/Outpatient records based on health record documentation.
    • Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
    • Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues.
• Medical Records Technician (Coder-Inpatient/Outpatient), GS-6:
  • (a) Experience: One year of creditable experience equivalent to the next lower grade.
  • (b) Demonstrated Knowledge, Skills, and Abilities:
    • Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
    • 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.
    • Ability to apply laws and regulations on the confidentiality of health information.
    • Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
    • Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS.
    • Knowledge 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/Outpatient), GS-7:
  • (a) Experience: One year of creditable experience equivalent to the next lower grade.
  • (b) Demonstrated Knowledge, Skills, and Abilities:
    • Skill in applying current coding classifications to a variety of inpatient/outpatient specialty care areas.
    • Ability to communicate with clinical staff for specific coding and documentation issues.
    • Ability to research and solve coding and documentation related issues.
    • Skill in reviewing and correcting system or processing errors.
    • Ability to abstract, assign, and sequence codes, including CC/MCC, and POA indicators, to obtain correct MS-DRG.
• Medical Records Technician (Coder-Inpatient/Outpatient), GS-8:
  • (a) Experience: One year of creditable experience equivalent to the next lower grade level.
  • (b) Demonstrated Knowledge, Skills, and Abilities:
    • Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient/outpatient coding.
    • Ability to accurately perform the full scope of inpatient/outpatient coding.
    • Skill in interpreting and adapting health information guidelines.

Benefits

• Work Schedule: Monday - Friday 8:00am - 4:30pm
• Compressed/Flexible: Not authorized.
• Telework: Available
• Relocation/Recruitment Incentives: Not authorized.
• Permanent Change of Station (PCS): Not authorized.
• PCS Appraised Value Offer (AVO): Not authorized.

Physical Requirements

The work is primarily sedentary. There is walking, bending, and reaching required such as for filing or locating material, and carrying items such as reports, documents, and supplies. Entering data and word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain.