Summary This position is located in the Health Information Management (HIM) section at the Durham VA Medical Center. MRTs (Coder-Inpatient) 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. Responsibilities Select and assign codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).Review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record. Use 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. Directly consult with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG).Enter and correct information that has been rejected, when necessary. Apply 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. Adhere 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. Assist 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. Work Schedule: Monday - Friday; 8:00 AM - 4:30 PM Compressed/Flexible: Yes Telework: Virtual/telework for highly experienced candidates Financial Disclosure Report: Not required Requirements Conditions of Employment Qualifications Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 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: 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; OR 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). Certification: Apprentice/Associate Level Certification through AHIMA or AAPC, OR Mastery Level Certification through AHIMA or AAPC. English Language Proficiency: Proficient in spoken and written English. Grade Determinations: In addition to meeting the basic requirements listed above, applicants must meet the grade requirements for Medical Records Technician (Coder-Inpatient). GS-04 Entry Level: None beyond the basic requirements. GS-05 Developmental Level 1: One year of creditable experience equivalent to GS-04 MRT (Coder-Inpatient) 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. Candidates must also demonstrate all of the following KSAs: 1. 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.). 2. Ability to navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting. 4. 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. 5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 6. Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues. GS-06 Developmental Level 2: One year of creditable experience equivalent to GS-05 MRT (Coder-Inpatient) and demonstrate all of the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to 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 HIPAA). 4. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. 5. 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. 6. 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-07 Developmental 3: One year of creditable experience equivalent to GS-06 MRT (Coder-Inpatient) and demonstrate all of the following KSAs: 1. 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. 2. 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. 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 comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG. GS-08 Full Performance Level: One year of creditable experience equivalent to GS-07 MRT (Coder-Inpatient) and demonstrate all of the following KSAs: 1. 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. 2. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, 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, Part II, Appendix G57, Medical Records Technician (Coder) Qualification Standard. The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html. Additional Information This job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members. If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
