Medical Records Technician (Coder-Outpatient/Inpatient)

Duties

This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.

Major Duties at the GS-8 MRT Coder Full Performance Level :

• Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• U se various computer applications to abstract records, assign codes, and record and transmit data.
• Code inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Query clinical staff with documentation requirements to support the coding process.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs.
• Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services.
• Correct any identified data errors or inconsistencies, also ensure audit findings have been corrected and refiled.
• Enter and correct information that has been rejected, when necessary.
• Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
• Review and code assigned fee service Care in the Community patient encounters (inpatient and outpatient) using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
• Code all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code 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 encounter for all billable surgical cases.

Work Schedule: Monday through Friday, 8:00 a.m to 4:30 p.m. (Schedule may change based on agency needs).

Remote: This is a remote position. (i.e., the employee will not work at a VA facility or VA-leased space). Typically, this means working from home 100%. Remote work requirements will be discussed during interview process.

Functional Statement #: 00000

Relocation/Recruitment Incentives: Not authorized

Permanent Change of Station (PCS): Not authorized

Financial Disclosure Report: Not required

Requirements

Conditions of Employment

• Selective Service Registration is required for males born after 12/31/1959.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• You must be a U.S. Citizen to apply for this job.
• A pre-placement evaluation required.
• Selected applicants will be required to complete an online onboarding process.
• Must be proficient in written and spoken English.
• 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.
• Subject to background/security investigation.
• You may be required to serve a probationary period.

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 (Coder) must be proficient in spoken and written English as required by 38 U.S.C.

• 7403(f).

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 degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information OR, 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 and physiology, medical coding, and introduction to health records). 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).

Persons Hired Or Reassigned To MRT (Coder) Positions In The GS-0675 Series In VHA Must Have Either (1), (2), Or (3) Below

Certification.

• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Mastery Level Certification through AHIMA or AAPC.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.
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).
Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:(1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.(2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.(3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.(4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.(5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.
Grade Determinations
Medical Records Technician (Coder-Outpatient and Inpatient), GS-8
Experience: One (1) year of creditable experience equivalent to the next lower grade level (GS-7).
and
Demonstrated Knowledge, Skills, and Abilities (KSA's): 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 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.
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.
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, Medical Record Technician (Coder) Qualification Standards,
The full performance level of this vacancy is GS-08.
Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.
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 is an open continuous vacancy announcement. Applicants will be referred periodically throughout the announcement period. Final application disposition will be completed once all positions have been filled or the announcement reaches the end of the open period stated in the announcement. The first cut-off date is 11:59 pm (EST), June 16, 2023.
For status updates on your application, please follow the directions listed in the How to Apply section.
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.
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.
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 .