This position is in the Health Information Management Service (HIMS) at the VA Finger Lakes HealthCare System (Bath or Canandaigua). 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. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Duties

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-04 to GS-08. Duties may include but are not limited to: GS-04 Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding. Incumbent with instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. GS-05 Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement. Links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Uses basic knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery Codes less complex Operating Room procedures reported in the Surgical Package of the VistA hospital system Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite Incumbent updates any assigned billable long stay (30+ days) inpatient admissions to reflect all patient conditions and care up for monthly billing. GS 6 Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC Incumbent has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Incumbent selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Incumbent monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment. Incumbent at the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs. GS 7 Serves as developmental level 3 MRTs (Coder) and receive minimal monitoring. MRTs (Coder) perform a combination of inpatient and outpatient coding duties Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Incumbent adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) 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. Incumbent 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. GS 8 Incumbent is at the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Independently plans and executes tasks related to medical record coding and documentation. Incumbent 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. All other duties as assigned. Work Schedule: Monday through Friday from 8:00am to 4:30pm. Telework: Position is suitable for telework depending on the organizational needs. Virtual: This is not a virtual position. Functional Statement #: Relocation/Recruitment Incentives: Not Authorized.

Requirements

Qualifications

Grade Determinations GS-04: Experience or Education. None beyond basic requirements GS-05: Experience: One year of creditable experience equivalent to the next lower grade level. OR Education. 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. 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. In addition to experience. 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, 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-06: Experience: One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. GS-07: Experience. At least one (1) year of experience equivalent to the next lower grade level. 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 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-08: Experience: At least one (1) year of experience equivalent to the next lower grade level. 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. 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 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. The full performance level is GS 08. References: VHA Handbook 5005/122 Part II Appendix G57 Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

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.

Contacts

• Address Canandaigua VA Medical Center 400 Fort Hill Ave Canandaigua, NY 14424 US
• Name: Terrence Davis
• Phone: 585-393-7208
• Email: [email protected]