Medical Record Technician (Coder-Outpatient and Inpatient)
Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. Applies 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 selection. Selects 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 coding. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record, and other duties as assigned. Work Schedule:
Monday-Friday 8:
00 am - 4:
30 pm Financial Disclosure Report:
Not required Remote Work:
Eligible for a highly qualified candidate To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 12/01/2020. Basic Requirements
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 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 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 Experience/Education Combination:
Equivalent combinations of experience and education are qualifying. The following educational/ training substitutions are appropriate :
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC Clinical Documentation Improvement Certification through AHIMA or ACDIS Grade Determinations:
MRT (Coder-Outpatient and Inpatient) GS-4 Experience or Education. None beyond basic requirements. GS-5 Experience. One year of experience equivalent to the next lower grade level or 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. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.) 2. Ability to navigate through and abstract pertinent information from health records 3. Knowledge of the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines 4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation 5. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelin 6. Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6 Experience. One year of experience equivalent to the next lower level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation 2. 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 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPPA)) 4. Ability to accurately apply the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios 5. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to both inpatient/outpatient records based on health record documentation 6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG GS-7 Experience. One year of experience equivalent to the next lower grade level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of inpatient/outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record 2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient/outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment. 3. Ability to research and solve coding and documentation related issues 4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete 5. Ability to abstract, assign, and sequence codes, including complication or CC/MCC, and POA indicators to obtain correct MS-DRG GS-8 Full Performance Level Experience. One year of experience equivalent to the next lower grade level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient 2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and inpatient professional services 3. 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 References:
VA Handbook 5005/79, Part II, Appx G57 MEDICAL RECORD TECHNICIAN Qualification Standard. Physical Requirements:
Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files.
Estimated Salary: $20 to $28 per hour based on qualifications.
Monday-Friday 8:
00 am - 4:
30 pm Financial Disclosure Report:
Not required Remote Work:
Eligible for a highly qualified candidate To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 12/01/2020. Basic Requirements
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 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 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 Experience/Education Combination:
Equivalent combinations of experience and education are qualifying. The following educational/ training substitutions are appropriate :
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC Clinical Documentation Improvement Certification through AHIMA or ACDIS Grade Determinations:
MRT (Coder-Outpatient and Inpatient) GS-4 Experience or Education. None beyond basic requirements. GS-5 Experience. One year of experience equivalent to the next lower grade level or 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. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.) 2. Ability to navigate through and abstract pertinent information from health records 3. Knowledge of the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines 4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation 5. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelin 6. Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6 Experience. One year of experience equivalent to the next lower level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation 2. 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 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPPA)) 4. Ability to accurately apply the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios 5. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to both inpatient/outpatient records based on health record documentation 6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG GS-7 Experience. One year of experience equivalent to the next lower grade level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of inpatient/outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record 2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient/outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment. 3. Ability to research and solve coding and documentation related issues 4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete 5. Ability to abstract, assign, and sequence codes, including complication or CC/MCC, and POA indicators to obtain correct MS-DRG GS-8 Full Performance Level Experience. One year of experience equivalent to the next lower grade level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient 2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and inpatient professional services 3. 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 References:
VA Handbook 5005/79, Part II, Appx G57 MEDICAL RECORD TECHNICIAN Qualification Standard. Physical Requirements:
Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files.
- Department:
0675 Medical Records Technician - Salary Range:
$43,061 to $71,604 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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