Inpatient MRTs(Coder) select codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG),and/or assigning CPT/HCPCS codes.

Duties

Duties included but not limited to: Inpatient MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance of a 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 professional services. They 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. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They must 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. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They ensure audit findings have been corrected and refiled. They 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. DEFINITIONS. a. Journey Level. The full performance level for the MRT (Coder) assignment is GS-8. b. Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder). c. Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means. d. Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time work week. For example, an MRT would receive one week of full-time credit for each two weeks of half-time work .e. Apprentice/Associate Level Certification. This is considered an entry level coding certification and is limited to certification obtained through the American Health Information Management Association (AHIMA), or the American Academy of Professional Coders (AAPC). See Education section of this vacancy announcement for additional information. f. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC.See Education section of this vacancy announcement for additional information. g. Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). See Education section of this vacancy announcement for additional information. Work Schedule: Monday - Friday 07:30am - 4:00pm Telework: ADHOC- VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process. Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required

Requirements

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. 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 a health records. OR, (2)Education. See education section for specific educational requirements; OR (3)Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year. See education section for additional information.; OR, (4)Experience/Education Combination. See education section for specific educational requirements. Preferred experience: Outpatient ambulatory surgery coding experience. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to the basic requirements, the below qualification requirements must be met at the grade(s) in which you are applying. Medical Records Technician (Coder-Inpatient), GS-4 (a)Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Inpatient).GS-5 (a)Experience. One year of creditable experience equivalent to the next lower grade;OR, (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.AND (d)Demonstrated Knowledge, Skills, and Abilities. 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. Medical Records Technician (Coder-Inpatient), GS-6 (a)Experience. One year of creditable experience equivalent to the next lower grade. (b)Demonstrated Knowledge, Skills, and Abilities. 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). Medical Records Technician (Coder-Inpatient), GS-7 (a)Experience. One year of creditable experience equivalent to the next lower grade. (b)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. 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 Medical Records Technician (Coder-Inpatient), GS-8 (a)Experience. One year of creditable experience equivalent to the next lower grade level. (b)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. References: VA Handbook 5005/122, Part II, Appendix G57The 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. Preferred Experience: Inpatient or outpatient coding experience References: VA Handbook 5005/122, Part II, Appendix G57 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. 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.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

(2)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,

(3)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,
(4)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).

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.

Contacts

• Address Robley Rex VA Medical Center 800 Zorn Avenue Louisville, KY 40206 US
• Name: Andrea Layman
• Phone: (858) 552-8585 X7050
• Email: [email protected]