Medical Records Technician (Coder-Outpatient and Inpatient)

Description:

This position is located in the Health Information Management (HIM) section at the Sierra Nevada Health Care System (VASNHCS). 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. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Requirements:

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 :

• Citizenship. Citizen of the United States.
• 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; 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:
• 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.
• 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. All MRT (Coders) 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

• Loss of Credential. An employee who fails to maintain the required certification must be removed from the occupation.
• English Language Proficiency. Must be proficient in spoken and written English.
• Grandfathering Provision. May apply

GRADE DETERMINATIONS
In addition to the basic requirements the following experience and/or education and all the knowledge, skills and abilities (KSAs) must be met for the grade.

Medical Records Technician (Coder-Outpatient/Inpatient), GS-04
Experience or Education. None beyond basic requirements.

Medical Records Technician (Coder-Outpatient/Inpatient), 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. AND

Demonstrated KSAs:

1. Ability to use health information technology and various office software products used in MRT (Coder) positions.
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.

Medical Records Technician (Coder-Outpatient/Inpatient), GS-06
Experience. One year of creditable experience equivalent to the next lower grade level. AND
Demonstrated 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.
3. Ability to apply laws and regulations on the confidentiality of health information.
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.
6. Knowledge of complication or comorbidity/major complication or comorbidity and POA indicators to obtain correct MS-DRG.

Medical Records Technician (Coder-Outpatient/Inpatient), GS-07
Experience. One year of creditable experience equivalent to the next lower grade level. AND
Demonstrated KSAs:

1. 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.
2. 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 and code assignment.
3. Ability to research and solve coding and documentation related issues.
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity, and POA indicators to obtain correct MS-DRG.

Medical Records Technician (Coder-Outpatient/Inpatient), GS-8
Experience . One year of creditable experience equivalent to the next lower grade level. AND
Demonstrated 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 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.
3. 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 5005/122 PART II APPENDIX G57 12/10/19

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-04 to GS-08.