This position is located in the Health Information Management (HIM) section at the VA Illiana 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

DUTIES: Select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. 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 medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. 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. Review provider health record documentation to ensure that it supports 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. Correct any identified data errors or inconsistencies. Ensure audit findings have been corrected and refiled. 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. All other duties as assigned. Work Schedule: 7:30 am to 4:00 pm, Monday to Friday; compressed tour may be available Telework: Eligible Virtual: Virtual/remote opportunities may be available for highly qualified applicants and will be discussed during the selection. Functional Statement #:GS-675 4-8 Financial Disclosure Report: Not required Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. The work does not require any special physical effort or ability. 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. References: VA Handbook 5005/122, Part II, Appendix G57, Medical Records Technician (Coder) Qualification Standards, December 10, 2019.

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: 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: At least one year of experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records. OR Education: An associate degree from an accredited college or university 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). Transcripts Required OR Completion of an AHIMA approved Coding Program: Completed 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. Transcripts or Certification of Program Completion Required. OR Experience/Education Combination: Equivalent combinations of experience and education are qualifying for meeting the basic requirements. The following education/training substitutions are appropriate for combining education and 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 of 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 experience that is paid or non-paid employment equivalent to MRT Coder. Grade Determination: In addition to the basic requirements, the following is the amount of experience required to qualify at the GS-4 through GS-8 grade level. GS-4 level Experience or Education: None beyond basic requirements. GS-5 level Experience or Education: One year of creditable experience equivalent to the next lower grade level (GS-4) or successful completion of a bachelor's degree from an accredited college or university, with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in heath information management or technology. Must demonstrate the following KSAs: Ability to utilize 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; and ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6 level Experience: One year of creditable experience equivalent to the next lower grade level (GS-5). Must demonstrate 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 in 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 based on health record documentation; and knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indictors to obtain correct MS-DRG. GS-7 level Experience: One year of creditable experience equivalent to the next lower grade level (GS-6). Must demonstrate 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 care documentation and code assignment; ability to research and solve coding and documentation related issues; and skill in reviewing and correcting system or processing errors and ensuring all assigned work is completed; and ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indictors to obtain correct MS-DRG. GS-8 level Experience: One year of creditable experience equivalent to the next lower grade level (GS-7). Must demonstrate 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. 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.

Contacts

• Address Danville VA Medical Center 1900 East Main Street Danville, IL 61832 US
• Name: Danielle Taylor
• Phone: 217-554-5951
• Email: [email protected]