Medical Records Technician (Coder-Inpatient)

Employer
USAJobs
Location
Salem, Virginia
Posted
Jul 04, 2022
Closes
Jul 07, 2022
Hours
Full Time
Duties

Major duties include but not limited to:
  • Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.
  • Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases­-Clinical Modification (ICD-10-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPD, and HCPCS.
  • Adheres 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.
  • 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 record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient records may be paper or electronic.
  • 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.
  • Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge: also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
  • Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access: competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
  • Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement: links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations: bundles encounters when appropriate: identifies non-billable encounters.
  • 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 inpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, military facilities, etc.
  • Codes all inpatient procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current codes set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE for all billable surgical codes.

Work Schedule: 7:45 AM to 4:30 PM; Monday - Friday
Telework: Available.
Virtual: This is a virtual position.
Functional Statement#: 000000
Relocation/Recruitment Incentives: Not Authorized.
Permanent Change of Station (PCS): Not Authorized.
Financial Disclosure Report: Not required.

Requirements

Conditions of Employment


  • You must be a U.S. Citizen to apply for this job.
  • Selective Service Registration is required for males born after 12/31/1959.
  • Must be proficient in written and spoken English.
  • You may be required to serve a probationary period.
  • Subject to background/security investigation.
  • Selected applicants will be required to complete an online onboarding process.
  • Must pass pre-employment physical examination.
  • Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
  • Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.


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.

English Language Proficiency: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Experience and Education:
  • Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR,
  • Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records). OR,
  • Experience/Education Combination: Equivalent combinations of experience and education are qualifying. (a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.
  • Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA 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.
  • Grade Determinations:GS-4 MRT (Coder):
    (a) Experience or Education. None beyond basic requirements.

    (b) Assignment. Employees at this level serve as entry level MRT coders and receive close supervision from more experienced MRT Coders.

    GS-5 MRT (Coder):
    (a) Experience: One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology.

    (b) In addition to the experience above, the candidate must demonstrate 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.
  • (c) Assignment: Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.

    GS-6 MRT (Coder):
    (a) Experience. One year of experience equivalent to the next lower level.

    (b) In addition to the experience above, the candidate must demonstrate 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.
  • 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).
  • (c) Assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.

    GS-7 MRT (Coder):
    (a) Experience. One year of experience equivalent to the next lower grade level.

    (b) In addition to the experience above, the candidate must demonstrate the following KSA's:
  • 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.
  • c) Assignment: Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.

    GS-8 MRT (Coder):
    (a) Experience. One year of experience equivalent to the next lower grade level.

    (b) In addition to the experience above, the candidate must demonstrate the following KSAs:
  • Ability to analyze the medical 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 medical 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/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and
  • Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

  • References: VA HANDBOOK 5005/122, PART II APPENDIX G57.

    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 Requirement: Light lifting, under 15 lbs., moderate carrying, 15-44 lbs., reaching above shoulder, use of fingers, standing 4-6 hours; hearing, aid permitted. Duties require extensive use of fingers to perform keyboarding and the ability to hear requests by phone and in person. Vision must be adequate to read and prepare documents.

    Education

    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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html .

    Additional information

    Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

    This job opportunity announcement may be used to fill additional vacancies.

    This position is in the Excepted Service and does not confer competitive status.

    VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

    To ensure compliance with an applicable preliminary nationwide injunction, which may be supplemented, modified, or vacated, depending on the course of ongoing litigation, the Federal Government will take no action to implement or enforce the COVID-19 vaccination requirement pursuant to Executive Order 14043 on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees. Therefore, to the extent a VA job announcement includes language requiring applicants to be fully vaccinated against COVID-19 pursuant to Executive Order 14043, that requirement does not currently apply to this Job Announcement. VA may request information regarding your vaccination status, if selected, for the purposes of implementing other workplace safety protocols, such as masking, physical distancing, testing, travel, and quarantine.

    If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application .