This position is located within Central Alabama VA Health Care System of the Veterans Health Administration (VHA). The person in this position serves as the Medical Records Technician (Coder - Outpatient and Inpatient) in the Health Information Management (HIM) section, providing classification of 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 include but are not limited to: Extensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Comprehensive knowledge in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Perform inpatient and outpatient coding duties; 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. 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. Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature; consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Utilize various computer applications to abstract records, assign codes, and record and transmit data. Resolve any identified data errors or inconsistencies and ensure audit findings have been corrected and refiled. Adhere to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Perform other duties as assigned. Work Schedule: Monday through Friday, 8:00 am - 4:30 pm; Tour of duty subject to change based on Agency needs. Telework: Available; as determined by the agency policy. Virtual: This is not a virtual position. Functional Statement #: PD51300F, 51299F, 51297F, 51298F, 51296F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): 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. 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 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/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 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 Experience/Education Combination. Equivalent combinations of creditable experience and education to meet the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: 6 months of 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. 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 experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification. Candidate must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. English Language Proficiency. Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Grandfathering Provision. 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: In addition to the basic requirements, the following criteria must be met when determining the grade of candidates: Medical Records Technician (Coder-Outpatient and Inpatient), GS-04: Experience or Education: None beyond basic requirements. Medical Records Technician (Coder-Outpatient and Inpatient), GS-05: Experience. One year of creditable experience equivalent to the next lower grade level (GS-4), OR Education. Successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education, with a major 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. In addition, 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 to follow-up on pending issues. Medical Records Technician (Coder-Outpatient and Inpatient), GS-06: Experience. One year of creditable experience equivalent to the next lower grade level (GS-5). Demonstrated Knowledge, Skills, and Abilities. In addition, 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 documentation's adequacy; Ability to determine if 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 health information confidentiality (e.g., Privacy Act, Freedom of Information Act, and HIPPA); Ability to accurately apply the ICD CM and 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, and HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation; Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). Medical Records Technician (Coder-Outpatient and Inpatient), GS-07: Experience. One year of creditable experience equivalent to the next lower grade level (GS-6). Demonstrated Knowledge, Skills, and Abilities. In addition, 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 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 CC/MCC, and POA indicators, to obtain correct MS-DRG.

Education

Medical Records Technician (Coder-Outpatient and Inpatient), GS-08:
Experience. One year of creditable experience equivalent to the next lower grade level (GS-7).
Demonstrated Knowledge, Skills, and Abilities. In addition, candidate must demonstrate all of the following KSAs:

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the documentation's adequacy. 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.

References: VA Handbook 5005, Part II, Appendix G57 Medical Records Technician (Coder) Qualification Standard.

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: See VA Directive and Handbook 5019, Employee Occupational Health Service.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Central Alabama VA Medical Center-Montgomery 215 Perry Hill Road Montgomery, AL 36109 US
• Name: Ju Ju Wang
• Phone: 508-846-2702
• Email: [email protected]