Duties

A Medical Records Technician (Coder) performs outpatient coding duties, or a combination of inpatient and outpatient coding duties. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services. Coders directly consult with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record and may also be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). They will also enter and correct information that has been rejected, when necessary, as well as, correct any identified data errors or inconsistencies. The basic functions of this position are listed below:

Assign codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.

Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.

Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD).

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.

Work Schedule: Monday-Friday 8:00 am - 4:30 pm EST
Virtual: This is not a virtual position. Virtual refers to work performed on a full-time basis using VA-leased space or at a VA facility other than the facility that hired the employee.
Remote: This is a remote position. Remote refers to work performed on a full-time basis anywhere other than at a VA facility or VA-leased space.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Physical Requirements: Lifting under 15 pounds; reaching above shoulder; use of fingers, both hands required; walking, standing; 20/20 vision required for both eyes; both eyes required; depth perception; ability to distinguish basic colors; ability to distinguish shades of colors; hearing (aid permitted).

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.
• Experience: 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure & format of a health record; OR,
• Education: 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 & physiology, medical coding, and introduction to health records); OR,
• Education: Completion of 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, 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 that qualify for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience: (a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and 1 year above high school, with 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 & professional supervision, may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques & procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to an MRT (Coder).
• Certification: Applicants must have 1 of the following, current, unexpired certifications:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certifications through AHIMA or ACDIS.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (applicable to current VHA employees who are in this occupation & meet the criteria).

Grade Determinations:
GS-4 Experience. None beyond basic requirements.

GS-5 Experience. 1 year of creditable experience equivalent to the next lower grade level; OR,
Education. Successful completion of a bachelor's degree from an accredited college/university recognized by the U.S. Department of Education, w/ a major field of study in health information management, or related degree w/ a minimum of 24 semester hours in health information management or technology.
Demonstrated KSA's. In addition to the education/experience above, must demonstrate all of the following:

• Ability to use health information technology and 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 and Reporting & CPT guidelines.
• Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records based on health record documentation.
• Knowledge of The Joint Commission requirements, Centers for Medicaid Services (CMS), and/or health record documentation guidelines.
• Ability to manage priorities & coordinate work to complete duties within required timeframes, and ability to follow-up on pending issues.

GS-6 Experience. 1 year of creditable experience equivalent to the next lower grade level.
Demonstrated KSA's. In addition to the experience above, must demonstrate all of the following:

• 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; includes 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 (Privacy Act, Freedom of Information Act, HIPAA).
• Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, and CPT guidelines to coding scenarios.
• Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, & skill in applying classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.

GS-7 Experience. 1 year of creditable experience equivalent to the next lower grade level.
Demonstrated KSA's. In addition to the experience above, must demonstrate all of the following:

• Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services 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, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation & coder assignment.
• Ability to research & solve coding & documentation related issues.
• Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete.

GS-8 Experience. 1 year of creditable experience equivalent to the next lower grade level.
Demonstrated KSA's. In addition to the experience above, must demonstrate all of the following:

• Ability to analyze the health record to identify all pertinent diagnoses & procedures for coding & to evaluate the adequacy of documentation; includes the ability to read & understand the content of the health record, terminology, significance of the findings, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies & procedures, and outpatient encounters, and/or inpatient professional fee services coding.
• Skill in interpreting & 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

Full performance level of this vacancy is GS-08. Actual grade at which an applicant may be selected for is in the range of GS-04 to GS-08.

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

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.

Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.

Due to COVID-19, VA is currently in an expanded telework posture. If selected, you may be expected to temporarily telework, even if your home is located outside the local commuting area. Once employees are permitted to return to the office, you will be expected to report to the duty station listed on this announcement. Management officials will provide information about returning to the official, pre-pandemic worksite, when applicable. At that time, you may be eligible to request to continue to telework depending upon the terms of your organization's telework policy and the duties of the position.

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 .