This position is located in the Health Information Management Service (HIMS) section within the Bay Pines VA Healthcare System at the Cape Coral location, 2.5 hours South of Bay Pines, FL. Medical Records Technician (Coder-Inpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices & multispecialty clinics.
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: Medical Records Technician must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Experience and Education: Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT work. OR, Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy and physiology, and introduction to health records). OR, Experience / Education Combination: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience: Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of six 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. Training 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 medical record techniques and procedures. The position requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: 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 MRT (Coder-Outpatient), GS-8 It is a requirement to have at least one year of specialized experience equivalent to the next lower grade level (GS-7), directly related to the position being filled that demonstrates the clinical competencies described at that level. KSAs at the GS-7 level are: 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. 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. 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. Demonstrated Knowledge, Skills, and Abilities In addition to the above listed required experience the candidate must demonstrate all of the following technical KSAs and demonstrate the potential to acquire the assignment-specific KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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/or inpatient professional fee services coding. 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. 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). Specialized Experience: MRT Coder - Outpatient, GS-8 - It is a requirement to have at least one year of specialized experience equivalent to the next lower grade level (GS-7), directly related to the position being filled that demonstrates the clinical competencies described at that level. KSAs at the GS-7 level are: 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. 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. 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. Demonstrated Knowledge, Skills, and Abilities (KSAs) - GS-8 - In addition to the above listed required experience the candidate must demonstrate all of the following technical KSAs and demonstrate the potential to acquire the assignment-specific 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 findings, 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/or inpatient professional fee services coding. 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 G-57. The full performance level of this vacancy is GS-8. Physical Requirements: The work is performed in an office setting which adequately lighted, heated and ventilated. The physical demands of the work are generally minor. The work is primarily sedentary (6-8 hrs.) although, there is some walking (1 hr.), bending (1 hr), and carrying of bulky files (1- 10 lbs.) and some extended periods of standing (2 hrs.).
Duties and task of the Medical Records Technician (Coder-Outpatient) include, but are not limited to the following: Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate. 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. Codes 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. Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounter. 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. Reviews and codes assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc Work Schedule: Monday - Friday 8:00am -4:30pm Telework: This position is telework eligible and exempted from return to office requirements. This position will be reviewed annually and do not imply permanent telework status. Current employees will be granted an exception to remain in the current duty station location if outside VISN 8. Functional Statement #: 10023F Permanent Change of Station (PCS): Not authorized.