Primary Purpose of the Position: Responsible for the assignment of appropriate codes to reflect the treatment provided to patients at this Medical Center. This medical center is large and complex and provides hospital based and clinic based outpatient services, acute medical, medical subspecialties, surgical, surgical subspecialties, psychiatric care, physical rehabilitation, substance abuse care as well as research and development services.
Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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. BASIC REQUIREMENTS. a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) b. Experience and Education (1) 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, (2) 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, (3) 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, (4) 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 4 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). c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. g. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f) 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 Determinations: Medical Records Technician (Coder-Outpatient and Inpatient), GS-8 (a) Experience. One year of creditable experience equivalent to the next lower grade level. (b) Assignment. 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 CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They 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. They 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. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. (c) 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 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 Preferred Experience: Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is 08. The actual grade at which an applicant may be selected for this vacancy is in the 08. Physical Requirements: See VA Directive and Handbook 5019.
Captures data through the Ambulatory Care Data Capture Superbill Form (both printed and electronic), electronic visit notes, the Quadra-med/DSS Complaint Coding Module (CCM), Patient Care encounter (PCE) and the Patient Treatment File (PTF) in Vista and in Quadra-med/DSS. Convert narrative electronic visit notes to ICD-10-CM/PCS, CPT-4 and HCPCS codes. Manually code from the medical record documentation and enter into the appropriate software packages. Inpatient data is captured by the Coders reading the electronic and paper medical record then converting the narrative to ICD-10-CM/PCS, CPT-4 and HCPCS codes. Validate data for accuracy of performance measurement, patient care, billing accuracy, reimbursement and research. Timely and accurate coding purpose of visit (diagnoses), services provided, practitioner, and other case mix data for all ambulatory and inpatient encounters. Maintain a control system to ensure comprehensive submission of all codes for the care provided into the Patient Care Encounter (PCE), Automated Information Capture System (AICS), Patient Treatment File (PTF), Appointment Management, Surgery Package and other applicable programs in VISTA. The ICD-10-CM/PCS, CPT-4 and HCPCS codes are updated bi-annually and annually and Medical Record Technicians must be knowledgeable in the changes. Insures physician documentation supports the diagnoses and procedures coded. Reviews the patient record. Provide technical advice to the professional staff. Assist professional staff in diagnostic/procedural sequencing. Complete Patient Treatment File (PTF), in Quadra-med and Vista by abstracting information, including clinical and demographic information, from the record. The entire patient record must be reviewed. Input information in the Quadra-med/DSS PTF and VISTA PTF computer systems for transmission to Austin. Perform corrective actions in response to PTF edit analysis listing for resubmitting to the Austin Automation Center. Responsible for retrospective as well as con-current coding. Codes diagnoses, operations and procedures (inpatient and outpatient), which requires knowledge in a variety of coding systems, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM/PCS), Current Procedural Terminology (CPT-4) and HCPCS Level II Code Book (HCPCS) ensuring completeness and conformance to accepted VA directives, JCAHO requirements, ICD-910 CM/PCS coding conventions and guidelines for optimal Diagnostic Related Group (DRG) assignment. Codes information from the patient medical record to generate a clinical care patient database for the Medical Center. Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner. Ensure that all diagnoses and procedures that may impact the facility's reimbursement are identified and documented by the physician, sequenced correctly and coded in an accurate and ethical manner for optimum reimbursement. Determine correct codes for routine, and/or new and unusual diagnoses and procedures not clearly listed in ICD-10-CM/PCS and CPT. Responsible for coding inpatient and Contract Nursing Home (CNH) quarterly Census and Monthly Closeout that, VHA Headquarters directive mandates. Knowledgeable of the Ambulatory Payment Classifications (APCs) and Diagnostic Related Group (DRG). Accurate and complete coding remains the primary responsibility of the MRT. Correct identification and coding of the principal diagnosis will determine the proper Diagnostic Related Group (DRG) for database and reimbursement. Assists physician, ancillary, administrative personnel and other clinical staff and ward clerks with concurrent documentation requirements in compliance with coding guidelines. Code third-party billing cases as a priority. Perform quantitative/qualitative analysis of outpatient/inpatient medical records. Provides assistance and guidance to clinicians. Required to organize and attend at least monthly in-service training sessions on coding and compliance issues and on technology advances. Perform quarterly quantitative analysis. Notify MACPAC on any coding changes that occur after the bill has been printed. Assists in completion of coding and data review for the quarterly patient census and other special surveys as mandated. Provides data analysis services and performs periodic data validation reviews of documentation and coding accuracy with recommendations to the lead, supervisor and Data Analyst relative to case mix reimbursement and performance measures. Performs other related record reviews and coding as requested and assigned by the lead or supervisor. Work Schedule: Monday - Friday, 8:00 a.m. - 4:30 p.m. Telework: Available. Virtual: This is not a virtual position. Functional Statement #: 59004F Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.