This position is located in the Health Information Management (HIM) section at the Iowa City VA Health Care Systems (ICVAHCS). The Medical Records Technician (Coder) is responsible for the technical duties related to abstracting medical record data and assigning codes using current clinical classifications systems appropriate for the type of care provided.
U.S. Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Experience & 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 Education 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. Dept. 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. Certification: 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. 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). Grade Determination:GS-4 Experience or Education. None beyond basic requirements. GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR Education. Completion of a bachelor's degree from an accredited college or university recognized by the U.S. Dept. 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, 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 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 outpatient/ambulatory surgery records, based on health record documentation. v. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. vi. Ability to manage priorities and coordinate work, in order 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. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and 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 Health Insurance Portability and Accountability Act (HIPAA)). iv. Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios. v. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation. GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated 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 specialty care areas for outpatient episodes of care and/or inpatient professional services 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 diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder 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. GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, 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 findings, 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/or inpatient professional fee services coding. 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. The full performance level of this vacancy is GS8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS4 to GS8. Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of the evaluation or examination.
Major duties include: Reviews and analyzes clinical medical record documentation for all specialties from CPRS and/or VistA Imaging to determine the reason for the episode, conditions addressed and all procedures performed. Specialties include but are not limited to Neurosurgery, Vascular, Orthopedics, Gastroenterology, Cardiology, Pulmonary, Psychiatry, and Primary Care/Medicine. Selects and assigns codes from the current version of one or more coding systems appropriate for the type of care provided. Current clinical classification systems include ICD-10-CM, CPT, and HCPCS. Sequences the codes appropriately. Assigns modifiers to CPT/HCPCS codes as appropriate. Reviews and analyzes clinical medical record and determines the primary and secondary diagnoses and procedure codes for billable outpatient encounters. Codes all billable outpatient encounters identified. Links the appropriate diagnoses to the procedures. May assist with the following duties if needed: Surgical coding: Reviews and analyzes clinical medical record documentation to accurately capture the reason for the surgery, the surgery performed, and any additional diagnoses or procedures related to the surgery for all procedures in the Surgical Package of VistA. A Assigns appropriate codes for all surgeries and cardiac catheterizations. Assigns codes for Anesthesia and Pathology encounters for all billable surgical cases. Links the appropriate diagnoses to the procedures. 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. Guidelines include the Official ICD-10 Guidelines for Coding and Reporting, the VHA Handbook for Coding Guidelines, VHA Resident Supervision Guidelines, and the Veterans Equitable Resource Allocation (VERA) program. Maintains current knowledge of regulatory and policy requirements affecting coded information. Ensures resident supervision guidelines are met when applicable. Reviews record documentation to abstract other required data, i.e. injury dates, referring providers, etc. Enters information into appropriate software package. Reviews all coding edits returned in encoder product and revises coding as appropriate. Reviews coverage determination issues regarding medical necessity of specific procedures and diagnostic tests if applicable. Ensures all documentation is present, accurate, complete and in an appropriate format. Ensures that documentation meets Joint Commission and VA requirements. Identifies problems in documentation and forwards to supervisor as necessary. Reviews documentation regarding conditions that have been adjudicated as a service connection (SC) condition or for special treatment authorities related to exposures or experiences and forwards to Utilization Review as appropriate. Communicates and interacts appropriately with a variety of staff from other areas/services (i.e. billing, utilization review, other coders, medical record specialists, scanning technicians, providers, etc.), for multiple reasons. Follows appropriate channels and communication methods outlined, (i.e., e-mail, spreadsheets, etc.). Work Schedule: 7:00 AM - 1530 PM, Monday- Friday Telework: Not Authorized Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized