This position is located in the Health Information Management (HIM) section at the Sioux Falls 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Duties

Major duties include, but are not limited to: Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. Has basic knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems 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 (E/M) code to ensure ethical, accurate, and complete coding. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Maintains current knowledge of regulatory and policy requirements affecting coded information. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic. With guidance from more experienced coding staff assists facility staff with basic documentation requirements, coding requirements, accepted nomenclature, and proper sequencing. Other questions are referred to the experienced coding staff for resolution. Insures provider documentation supports the diagnoses and procedures coded. Consults with a more senior coder or the supervisor to resolve issues related to conflicting or questionable clinical documentation. Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment. Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts a senior coder or supervisor when needed. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and procedure codes are selected from the current version of the ICD coding system. Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement. 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; receives guidance from experienced coder to interpret instructional notations or to bundle encounters or to identify non-billable encounters. Codes less complex Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases. Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Work Schedule: 08:00 to 16:30 Telework: Telework, if approved, will be on an Ad-Hoc basis only. Virtual: This is not a virtual position. 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. English Proficiency: MRT Coders must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Basic Requirements: 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. 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). (TRANSCRIPT REQUIRED), 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. (TRANSCRIPT REQUIRED) OR 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: 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. (TRANSCRIPTS REQUIRED). 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 an MRT (Coder). (DOCUMENTATION REQUIRED) Certification: Persons hired or reassigned to MRT (Coder) positions must be certified. a) Apprentice/Associate Level Certification through AHIIMA or AAPC. b) Mastery Level Certification through AHIMA or AAPC. c) Clinical Documentation Improvement Certification through AHIMA or AAPC. Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists. 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. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). 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). Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: 1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or place in supervisory or managerial positions. 2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. 3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. 4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation. 5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. Grade Determinations: See Education for Grade Requirements. References: VA Handbook 5005, Part II, Appendix G57, Medical Record Technician (Coder) Qualification Standard, dated December 10, 2019. 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: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of evaluation or examination.

Education

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

Grade Determinations:
GS-4:
Basic Requirements

GS-5:
You have one year of creditable experience equivalent to the GS-4 grade level 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. In addition to the experience above, you must demonstrate all of the following KSAs.
i. 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.).
ii. Ability to navigate through and abstract pertinent information from health records.
iii. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
iv. 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.
v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
vi. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

GS-6:
You have one year of creditable experience equivalent to the GS-5 grade level. In addition to the experience above, you must demonstrate all of the following KSAs.
i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
ii. 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.
iii. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
iv. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
v. 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.
vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7:
You have one year of creditable experience equivalent to the GS-6 grade level. In addition to the experience above, you must demonstrate all of the following KSAs.
i. 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.
ii. 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.
iii. 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.
v. 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:
You have one year of creditable experience equivalent to the GS-7 grade level. In addition to the experience above, you must demonstrate all of the following KSAs.
i. 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.
ii. 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.
iii. 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.

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 Royal C Johnson Veterans Memorial Hospital 2501 West 22nd Street Sioux Falls, SD 57105 US
• Name: Jason Arcand
• Phone: 612-629-7118
• Email: [email protected]