Medical Records Technician - Coder Inpatient

Description:

This position is located in the Health Information Management (HIM) section at the Salt Lake City VA Medical Center. 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 alpha­numeric codes for each diagnosis and procedure.

Requirements:

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: MRT Coders must be proficient in spoken & written English as required by 38 U.S.C. § 7403(f)

Experience and/or Education: Must have 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure & format of health records
OR
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/management (e.g., courses in medical terminology, anatomy/physiology, medical coding, & introduction to health records)
OR
Completed an AHIMA approved coding program, or other intense coding training program of approximately 1 year or more that included courses in anatomy & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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
Have a combination of experience/education. The following educational/training substitutions are appropriate for combining education & creditable experience:

• Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, & 1 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 & 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, & health record techniques & 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 VHA must have either:

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

Grade Determinations :
GS4
Experience or Education: None beyond basic requirements

GS5
Experience or Education: Must have 1 year of creditable experience equivalent to the next lower grade level of GS4
OR
Successful completion of a bachelor's degree from an accredited college/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, & Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of the following KSAs:

• Ability to use health information technology & various office software products used in MRT Coder positions (e.g., the electronic health record, coding & abstracting software, etc.)
• Ability to navigate through & abstract pertinent information from health records
• Knowledge of the ICD CM & PCS Official Conventions & Guidelines for Coding & Reporting
• Ability to apply knowledge of medical terminology, human anatomy/physiology, & 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 & coordinate work to complete duties within required timeframes & the ability to follow-up on pending issues

GS6
Experience: 1 year of creditable experience equivalent to the next lower grade level of GS5

Demonstrated Knowledge, Skills, & Abilities (KSAs): 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 & procedures for coding & 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, & 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 & regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, & HIPAA)
• Ability to accurately apply the ICD CM & PCS Official Conventions & Guidelines for Coding & Reporting to various coding scenarios
• Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) & PCS, CPT, & HCPCS, & skill in applying said classifications to inpatient records based on health record documentation
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG)

GS7
Experience: 1 year of creditable experience equivalent to the next lower grade level of GS6

Demonstrated Knowledge, Skills, & Abilities (KSAs): 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 & care provided based on documentation in the health record
• Ability to communicate with clinical staff for specific coding & documentation issues, such as recording diagnoses & procedures, the correct sequencing of diagnoses and/or procedures, & the relationship between health record documentation & code assignment
• Ability to research & solve coding & documentation related issues
• Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete
• Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators, to obtain correct MS-DRG

GS8
Experience: 1 year of creditable experience equivalent to the next lower grade level of GS7

Demonstrated Knowledge, Skills, & Abilities (KSAs): 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 & procedures for inpatient coding & to evaluate the adequacy of the documentation. This includes the ability to read & understand the content of the health record, the terminology, the significance of the comments, & the disease process/pathophysiology of the patient
• Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services
• Skill in interpreting & adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, & the ability to use judgment in completing assignments using incomplete or inadequate guidelines

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/ .

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 GS4 to GS8.

Physical Requirements: See VA Directive & Handbook 5019, Employee Occupational Health Service.