Medical Records Technician (Coder Inpatient)

This position is located in the Health Information Management section of the Business Office at the James J. Peters VA Medical Center. 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. This is a Remote Position. Final pay will be determined based on the VA approved GS locality scale of the selected candidate.

Qualifications:

Basic Requirements:
Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. MRTs (Coder) must be proficient in spoken and written English.
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series 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 or ACDIS.
Experience and Education
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 creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and 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 health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
Grade Determinations:
The full performance level of this vacancy is GS-8. The actual grade at which at which an applicant may be selected for this vacancy is in the range of a GS-4 to GS-8.

GS-4 Experience or Education. None beyond basic requirements.

GS5
Experience. One year of creditable experience equivalent to the next lower grade level;
OR
Education. 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 Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs.
Ability 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.)- 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 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
GS-6
Experience. One year of creditable experience equivalent to the next lower grade level
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs.
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. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable- Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA)- 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, and skill in applying said classifications to inpatient records based on health record documentation- Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG
GS-7
Experience. One year of creditable experience equivalent to the next lower grade level
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs- Skill 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 record- Ability 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 assignment. iii. Ability to research and solve coding and documentation related issues. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG
GS-8
Experience. One year of creditable experience equivalent to the next lower grade level
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation. This 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 patient. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services- 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.

Reference: VA Handbook 5005/122 Pt II Appendix G57

Responsibilities:

Inpatient MRTs (Coder) select and assign codes from current versions of ICD (International Classification of Diseases) CM (Clinical Modification) and the PCS (Procedural Coding System), and/or CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) classification systems for inpatient facility and/or professional services. The MRT( Coder-Inpatient) may also provide education related to coding and documentation. Assign codes to documented Patient Treatment Files (PTFs); PTFs are often complicated and complex requiring extensive coding expertise. 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 one or more coding systems depending on regular/recurring duties. Coding systems include International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding Systems (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding Systems (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis operation, or procedure code to ensure ethical, accurate, and complete coding.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 or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

Work Schedule: Monday - Friday 8:00am to 4.30pm (EST)
Financial Disclosure Report: Not required
Bargaining Unit: Yes

Salary : $0