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Medical Records Technician (Coder- Outpatient and Inpatient)

Company: Department of Veterans Affairs
Location: North Little Rock
Posted on: June 8, 2021

Job Description:

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Summary

If you are not a current, permanent VA employee or Federal employee from another agency, you should apply under CBST-11117134-21-ER.

This position is located in the Health Information Management (HIM) section at the Central Arkansas Veterans HealthCare System in North Little Rock, AR. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Learn more about this agency

Responsibilities

The duties of the Medical Records Technician (Coder-Outpatient and Inpatient) in Central Business Office include but are not limited to:

  • Incumbent assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise.
  • Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (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 health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health 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.
  • Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
  • Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, Citrix, Access and Nuance; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
  • Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
  • Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
  • 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).
  • Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
  • Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program.
  • 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 Evaluation & Management service provided.
  • When appropriate Codes 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.
  • 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 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.
  • Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Monday - Friday 7:30am-4pm or 8am-4:30pm as best meets the needs of the Service. Position can be virtual/telework eligible.

Financial Disclosure Report: Not required

Travel Required

Not required

Supervisory status

No

Promotion Potential

8

  • Job family (Series)

0675 Medical Records Technician

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  • Requirements

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Requirements

Conditions of Employment

  • You must be a U.S. Citizen to apply for this job
  • Designated and/or random drug testing may be required
  • Selective Service Registration is required for males born after 12/31/1959
  • You may be required to serve a probationary period
  • Subject to a background/security investigation
  • Must be proficient in written and spoken English
  • Selected applicants will be required to complete an online onboarding process

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 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 (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: (a) 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. (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 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: Must have either: Apprentice/Associate Level Certification through AHIMA or AAPC; OR Mastery Level Certification through AHIMA or AAPC, OR Clinical Documentation Improvement Certification through AHIMA or ACDIS.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation.

Grade Determinations:

GS-4

Experience or Education. None beyond basic requirement.

GS-5

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.

Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

i.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.).

ii.Ability to navigate through and abstract pertinent information from health records.

iii.Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.

iv.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.

v.Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.

vi.Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

GS-6

Experience. One year of creditable experience equivalent to the next lower grade level.

Knowledge, Skills, and Abilities. 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.

ii.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.

iii.Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).

iv.Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.

v.Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.

vi.Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7

Experience. One year of creditable experience equivalent to the next lower grade level.

Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

i.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.

ii.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.

iii.Ability to research and solve coding and documentation related issues.

iv.Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

v.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.

GS-8:

Experience: One year of creditable experience equivalent to the next lower grade level.

Knowledge, Skills, and Abilities. In addition to the experience, the candidate must demonstrate all of the following KSAs:

i.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.

ii.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.

iii.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.

See Education section for physical requirements.

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.

References: VA Handbook 5005/122, Part II Appendix G57 dated 12/10/2019, Medical Records Technician (Coder) Qualification Standard. This can be found in the local Human Resources Office.

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 Requirements: Light lifting (Under 15 pounds), use of fingers and both hands required, ability to distinguish basic colors and shades of colors, both eyes required, and ability to be in multiple postures for 8 hours per day. Will work closely with others (See VA Directive and Handbook 5019, Employee Occupational Health Services).

Keywords: Department of Veterans Affairs, North Little Rock , Medical Records Technician (Coder- Outpatient and Inpatient), Other , North Little Rock, Arkansas

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