This position is located in the Health Information Management(HIM) section at the Hershel Woody Williams VA Medical Center. Medical Records Technicians (Coders) are skilled in classifying medial data from patient health records in the hospital setting, and/or physician-based settings. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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. 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 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: MRT (Coder-Outpatient and Inpatient) GS-4 Experience or Education. None beyond basic requirements. MRT (Coder-Outpatient and Inpatient) 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. In addition to the experience above, candidate must demonstrate all KSAs 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.). Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines 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. Acknowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. MRT (Coder-Outpatient and Inpatient) GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, candidate must demonstrate all KSAs Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and 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, 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. Ability to apply laws and regulations on the confidentiality of health information (e.g. Privacy Act, Freedom of Information Act, and HIPAA). Ability to accurately apply the ICD CM PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. Comprehensive knowledge of current classification systems, such as ICD CM PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. MRT (Coder-Outpatient and Inpatient) GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, candidate must demonstrate all KSAs 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 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 Ability to research and solve coding and documentation related issues Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete 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. GRADE REQUIREMENTS FOR THIS POSITION AT THE GS-08 LEVEL CONTINUE IN THE "HOW YOU WILL BE EVLAUATED" SECTION BELOW. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. 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.
Total Rewards of a Allied Health Professional Major Duties include, but are not limited to: Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding. With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record. Adheres to accepted coding practices guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluations and management(E/M) code to ensure ethical, accurate, and complete coding. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. 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. 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. Work Schedule: Full-Time, Monday-Friday 8:00am - 4:30pm Recruitment Incentive (Sign-on Bonus): Not authorized. Permanent Change of Station (Relocation Assistance): Not authorized. Pay: Competitive salary and regular salary increases. Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Regular telework available of 6+ days per pay period as determined by agency policy. Virtual: This is not a virtual position. Functional Statement #: 581-23167-F, 581-23168-F, 581-23169-F, 581-23170-F, and 581-23171-F Permanent Change of Station (PCS): Not authorized.