This position is located in the Health Information Management (HIM) section at the Lexington, Kentucky VA Health Care System. 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

This job opportunity announcement (JOA) will be used to fill one (1) full-time, permanent Medical Records Technician (Coder-Outpatient) vacancy at the Lexington, KY Veteran Affairs Medical Center (VAMC), with Heath Administrative Service. This position is located in the Health Information Management (HIM) section at the Lexington, Kentucky VA Health Care System. 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. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRTs (Coder) may also provide education related to coding and documentation. This is the journey level for this assignment. Outpatient MRTs (Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. Major duties for the Medical Records Technician (Coder-Outpatient) include (but are not limited to) : Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management 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. Code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties. They also directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. MRTs (Coder) must abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected, when necessary. MRTs (Coder) ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data. Performs other duties as assigned. Work Schedule: Monday - Friday, tour of duty flexible between the hours of 6:00 am and 6:00 pm. (Tour of duty will be fixed 8 hours.) Telework: Available for highly qualified applicants. Virtual: This is not a virtual position. Position Title/Functional Statement #: Medical Records Technician (Coder-Outpatient)/30305-F Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. Financial Disclosure Report: Not required

Requirements

Qualifications

Basic Requirements: United States Citizenship: Physical Requirements. See VA Directive and Handbook 5019. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). 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 (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. 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. 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). Preferred Experience: Prior coding experience in multi-disciplinary outpatient setting(s) and/or surgical/ procedure coding is preferred. In addition to the basic requirements, the below qualification requirements must be met at the grade in which you are applying. Grade Determinations: Medical Records Technician (Coder-Outpatient), GS-04 (a) Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Outpatient), GS-05 (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR, (b) Edu. 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 the experience or education above, the candidate must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding 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 outpatient/ambulatory surgery records, based on health record documentation. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. Medical Records Technician (Coder-Outpatient), GS-06 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 analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and 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 Health Insurance Portability and Accountability Act (HIPAA). Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation. Medical Records Technician (Coder-Outpatient), GS-07 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: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services 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, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment. Ability to research and solve coding and documentation related issues. iv. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. Medical Records Technician (Coder-Outpatient), GS-08 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 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 findings, 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/or inpatient professional fee services coding. 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.

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.

Qualifications (Con't)

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.

Contacts

• Address Lexington VA Health Care System 2250 Leestown Road Lexington, KY 40511 US
• Name: Julissa Jimenez
• Phone: (407) 579-4973
• Email: [email protected]