The Medical Records Technician (MRT) Outpatient Coder classify medical data from patient health records in a hospital setting, and/or physician-based settings. They analyze & abstract patients' health records, assign alpha-numeric codes for each diagnosis/procedure. They must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). May provide education related to coding & documentation.

Duties

Basic Duties: Assigns codes to documented patient care encounters (outpatient and/or inpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated & complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures & the principles/practices of health services & the organizational structure to ensure proper code selection. Selects/assigns codes from the 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 & 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 applies codes based on guidelines specific to certain diagnoses, procedures, & other criteria used to classify patients under the VERA program that categorizes all VA patients into specific classes representing their clinical conditions & resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, & administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services & patient population, to determine budgetary requirements, to report to accrediting & peer review organizations, to bill insurance companies & other agencies, & to support research programs. Assists facility staff with documentation requirements to completely & accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, & proper sequencing. Insures provider documentation is complete & supports the diagnoses & procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization & structure of the patient record. Utilizes the facility computer system and software applications to correctly 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. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate. 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. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, & use of an electronic health record. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; & copes with frequently changing projects & deadlines. May be assigned to a single facility or region, such as a consolidated coding unit. Work Schedule: Monday to Friday, 8:00am to 4:30pm Telework: Eligible Virtual: Eligible Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

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: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C 7403(f). Experience and Education: 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 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 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 Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that includes 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 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. AND 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). Certification: Persons hired or reassigned to the MRT (Coder) positions in the GS-0675 series in VHA must have one of the following: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: Mastery level certification is required for all positions above the journey level (GS-8); however, for clinical documentation improvement specialists assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. 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: GS-4, Medical Records Technician (Outpatient Coder) Entry Level Experience or Education: None beyond basic requirements. GS-5, Medical Records Technician (Outpatient Coder) Developmental Level 1 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. Demonstrated Knowledge, Skills, and Abilities: Resume must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions. 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 to accurately assign codes on health record documentation. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. Ability to manage priorities and coordinate work to complete duties within required timeframes. GS-6, Medical Records Technician (Outpatient Coder) Developmental Level 2 Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities: Resume must demonstrate all of the following KSAs: Ability to analyze health information technology and software products used in MRT (Coder) positions. 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 to accurately assign codes on health record documentation. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. Ability to manage priorities and coordinate work to complete duties within required timeframes. GS-7, Medical Records Technician (Outpatient Coder) Developmental Level 3 Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities: Resume must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of specialty care areas/services, to accurately reflect services based on documentation in the health record. Ability to communicate with clinical staff for specific coding and documentation issues. Ability to research/solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. GS-8, Medical Records Technician (Outpatient Coder) Full Performance Level/Journey Level Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities: Resume 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 accurately perform the full scope of outpatient encoding. 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 judgement in completing assignments using incomplete or inadequate guidelines. Preferred Experience: CTP and ICD-10 knowledge Inpatient and Outpatient coding experience Multitasking References: VA Handbook 5005/122, Part II, Appendix G57 (PDF page 1179) 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-4 to GS-8. Physical Requirements: See guidance in VA Handbook 5019, Part II, Ch 4 (a)(1)(b).

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 White City VA Medical Center 8495 Crater Lake Highway White City, OR 97503 US
• Name: Angela Wilson VAPORHCS
• Phone: (816) 812-9502
• Email: [email protected]