This position is located in the Health Information Management (HIM) section at the William S. Middleton Memorial VA Hospital. The incumbent is responsible for abstraction of clinical information for ongoing regulatory reviews. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems.

Duties

VISN 12 is committed to fostering and sustaining an environment which celebrates diversity, provides equitable opportunities for employment and promotion, and supports inclusiveness in our culture. Together, we strive to create and maintain working and learning environments that promote professional growth and teamwork, and are inclusive, equitable and welcoming. We embrace our differences as individuals and unite as a team toward a common goal: to serve our nation's Veterans. This position is located in the Health Information Management (HIM) section at William S. Middleton Veterans Hospital, 3220 Deming Way, Middleton, WI 53562. MRT (Coder) is responsible for abstraction of clinical information for ongoing regulatory reviews. Duties Include: GS-4 Basic Entry Level: MRT (Coder) - They 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. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. GS-5 Developmental Level 1: MRT (Coder) - Selects and assigns codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. GS-6 Developmental Level 2: MRT (Coder) - MRTs (Coder) perform a combination of inpatient and outpatient coding duties. They select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with limited guidance from higher level MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. GS-7 Developmental Level 3: MRT (Coder) - MRTs (Coder) perform a combination of inpatient and outpatient coding duties. Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with minimal guidance from higher level MRTs (Coder). They 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. They review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They also query clinical staff with documentation requirements to support the coding process. They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. GS-8 Full Performance Level: MRT (Coder) - MRTs (Coder) 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. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-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-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. Review and abstract clinical data from the record for documentation of diagnoses and procedures. 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. *Due to space constraints, please look under "Education" in the overview to find the "Continuation of Duties for GS-8". Work Schedule: Monday-Friday 8:00am-4:30pm Telework: Available, determined by agency policy. 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: Proficient in spoken and written English as required by 38 USC 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 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); 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 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). 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. 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 above, candidates must also meet any additional requirements to include KSAs based on grade assignment below Medical Records Technician (Coder-Outpatient/ Inpatient), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Outpatient/Inpatient), GS-5 (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR, (b) 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 field of study in health information management or a related degree with a minimum of 24 semester hours in health information management or technology.(c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the 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 and PCS Official Conventions and Guidelines for Coding and Reporting. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records 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 the ability to follow-up on pending issues. Medical Records Technician (Coder-Outpatient/Inpatient), GS-6 (a) Experience. One year of creditable experience equivalent to the next lower grade level.(b) Demonstrated Knowledge, Skills, and Abilities. 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. 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 HIPAA). Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient 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). *Please look under "Education" in the overview to find the qualifications for the GS-7 and GS-8. Due to space constraints under "Qualifications", the information had to be moved under another section.* Preferred Experience: None References: VA Handbook 5005/122 Appendix G57 Part II, 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: Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; both hands required; hearing (aid permitted); sitting for up to 8 hours; repetitive motions for computer data entry.

Education

**CONTINUATION OF DUTIES FOR GS-8**
They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They 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. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data.

**QUALIFICATIONS**
Medical Records Technician (Coder-Outpatient/Inpatient), GS-7
(a) Experience. One year of creditable experience equivalent to the next lower grade level.(b) Demonstrated Knowledge, Skills, and Abilities. 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 inpatient 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 comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG.

Medical Records Technician (Coder-Outpatient/Inpatient), GS-8
(a) Experience. One year of creditable experience equivalent to the next lower grade level.(b) Demonstrated Knowledge, Skills, and Abilities. 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 inpatient 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 inpatient 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

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 William S Middleton Memorial Veterans Hospital 2500 Overlook Terrace Madison, WI 53705 US
• Name: Angela McFadden
• Phone: (314) 893-4821
• Email: [email protected]