Medical Records Technicians (Coder - Outpatient and Inpatient) are skilled in classifying medical data from patient health records including analyzing and abstracting patient's health records and assigning alpha-numeric codes for each diagnosis and procedures.

Duties

The duties of the Medical Records Technician (Coder-Outpatient and Inpatient) include, but are not limited to: Assigns codes to documented patient care encounters (inpatient and outpatient) for the specialty and subspecialty health care services provided by the VAMC utilizing advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment, diagnostic tests, medication, procedures and accepted health care services to ensure proper code selection; Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties; Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC; Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative date to ensure complete data capture; Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing; Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of organization and 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. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines; Utilizes various computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, Access, health record applications (VistA and CPRS) and 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, and use of electronic health record; Works within a team environment supporting peers in meeting goals and deadlines; Identifies the principal diagnosis and principal procedures for every inpatient discharge; Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG), Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed and corrects coding as needed to ensure proper patient classification in the VERA program. Codes inpatient professional fee services for identified inpatient admission. Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions and requirements for allowable reimbursement; Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay admissions to reflect all patient conditions and care up to the census date or to the requested billing date; Reviews and codes assigned fee service Care in the Community patient encounters (inpatient and outpatient) using the paper or electronica documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.; and Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Work Schedule: Monday through Friday, 7:00 am - 3:30 pm (subject to change based on the needs of the agency) Telework: Available Virtual: This is not a virtual position Functional Statement #: 00719F, 00720F, 00721F, 00722F, 00723F 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: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. 7403(f). Education/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., course in medical terminology, anatomy and physiology, medical coding, and introduction to health record); 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 must have led to eligibility for coding certification examination, and the sponsoring academic institution must have been accredited by the 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 combination of creditable experience and education are qualifying for meeting the basic requirements. The following education/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 health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of course for medical technicians, hospital corpsmen, medical service specialist, or hospital training obtained in the 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 Certificate through American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC). (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or Association of Clinical Documentation Improvement Specialists (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: GS-04: Experience. Experience or Education. None beyond basic requirements. GS-05: Experience. One year of creditable experience equivalent to the next lower grade level; 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 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, the candidate must demonstrate all of the following KSAs: 1. 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.). 2. Ability to navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. 4. 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. 5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. (KSAs must be clearly reflected in resume under description of duties in order to be found qualified for this position/grade level). GS-06: Experience. One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2. 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. 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). 4. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. 5. 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. (KSAs must be clearly reflected in resume under description of duties in order to be found qualified for this position/grade level). GS-07: Experience. One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, the candidate must demonstrate all the following KSAs: Skills 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 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 record documentation ad 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. 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: Physical aspects associated with work required of this assignment are typical for the occupation. Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated.

Education

Continuation from Qualifications:

Medical Records Technician (Coder-Outpatient and Inpatient), GS-8
One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, the candidate must demonstrate all the following KSAs:

1. 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.
2. Ability to accurately perform the full scope of outpatient coding, including ambulator 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.
3. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgement in completing assignments using incomplete or inadequate guidelines.

Preferred Experience: Outpatient Coding- Multi-Specialty such as Primary Care, Emergency Room,
Surgical Specialties, Mental Health, Optometry and Radiology etc. Knowledge of Inpatient Coding, CPRS, and Vista.

References: VA Handbook 5005/122, Part II Appendix G57, Medical Records Technician (Coder), Qualification Standard dated December 10, 2019.


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 Fayetteville AR VA Medical Center 1100 North College Avenue Fayetteville, AR 72703 US
• Name: SUSAN WILLIAMS
• Phone: 228-523-4934
• Email: [email protected]