Medical Records Technician (Coder) (Outpatient & Inpatient)

Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens. Certification. MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below. NOTE: Certificate submitted must be a current and active certificate. (1) Apprentice/Associate Level Certification through AHIMA or AAPC. OR (2) Mastery Level Certification through AHIMA or AAPC. OR (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: You will be disqualified if you do not submit your certification OR you submit an expired certification. 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; OR Education: An associate's degree from an accredited college or university recognized by the U.S. Dept. of Ed., 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 AHIMA Coding Program: Completion of an AHIMA approved coding program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. Program must have led to coding certification/certification examination, and accredited by a national U.S. Dept. of Ed. accreditor, or comparable international accrediting authority; OR Experience/Education Combination: 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 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 may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Grade Determinations: GS-5 Experience/Education Requirement: In addition to the basic requirements, you must possess one of the following: One year of experience equivalent to the next lower grade level (GS-4), OR Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university recognized by the U.S. Dept. of Ed., 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. AND Demonstrate the following knowledge, skills, and abilities (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, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. Ability 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 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 Requirement: In addition to the basic requirements, you must possess 1 year of experience equivalent to the next lower grade level (GS-5). AND Demonstrate the following knowledge, skills, and abilities (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, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. Comprehensive 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 documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. GS-7 Experience Requirement: In addition to the basic requirements, you must possess 1 year of experience equivalent to the next lower grade level (GS-6). AND Demonstrate the following knowledge, skills, and abilities (KSAs): Skill in applying current coding classifications to a variety of inpatient and outpatient 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 inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. 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 Requirement: In addition to the basic requirements, must have 1 year experience equivalent to the next lower level, GS-7. AND Candidates must demonstrate these KSAs: Analyze the health 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 health record, the terminology, the significance of the comments, and the disease pathophysiology of the patient. Accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. Interpreting and adapting health information guidelines that are not 18 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: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8. Physical Requirements: The work is primarily sedentary. This position is located in the Health Information Management (HIM) section at the Kansas City 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.

• Duties include but are not limited to: Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. 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. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the health record applications (VistA and CPRS) as well as the encoder product suite. Work Schedule: Mon.- Fri. 7am-3:30pm CST Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)Virtual: This is a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized VA Careers - Pharmacy: https://youtube.com/embed/Fn_ickNBEws VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU VA Careers - Licensed Clinical Social Worker: https://youtube.com/embed/U_xC25QsN0w VA Careers - Microbiology/Molecular Medical Technologist: https://youtube.com/embed/eSDGhIwZKdw VA Careers - Diagnostic Radiologic Technologist: https://youtube.com/embed/I-4ku5UMvWM VA Careers - Medical Support Assistant: https://youtube.com/embed/EE9c4XkaELo VA Careers - Lead Medical Support Assistant: https://youtube.com/embed/UJO_XH5uCLs VA Careers - Licensed Practical Nurse: https://youtube.com/embed/Ae85IP1Oiz4 VA Careers - Psychologist: https://youtube.com/embed/77qHlLw9XckTotal Rewards of a Allied Health Professional