Med Rec Tech (Coder In/Out)

Description:

This position is located in the Health Information Management (HIM) section of the Business Office at the Orlando VA Healthcare System. MRTs (Coders) 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, and specialty centers.


*** ALL APPLICANTS MUST POSSESS A CURRENT MRT CERTIFICATION THROUGH AHIMA OR AAPC . A COPY MUST BE SUBMITTED WITH YOUR APPLICATION.

Requirements:

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.

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 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 t o 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.

English Language Proficiency . MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).


*** ALL APPLICANTS MUST POSSESS A CURRENT MRT CERTIFICATION THROUGH AHIMA OR AAPC AND A COPY MUST BE SUBMITTED WITH YOUR APPLICATION.***

Grade Determinations : Medical Record Technician (Coder-In/Outpatient)

(1) Medical Records Technician (Coder-In/Outpatient), GS-4

• (a) Experience or Education. None beyond basic requirements.
• (b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM and the PCS, and/or, CPT and HCPCS classification systems for inpatient facility and/or professional services. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder). They also use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

(2) Medical Records Technician (Coder-Inpatient), GS-5

• (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR,
• (b) 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.
• (c) Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (d) Demonstrated Knowledge, Skills, and Abilities. (For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)

(3) Medical Records Technician (Coder-Inpatient), GS-6

• (a) Experience. One year of creditable experience equivalent to the next lower grade level.
• (b) Assignment. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (c) Demonstrated Knowledge, Skills, and Abilities. (For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)

(4) Medical Records Technician (Coder-Inpatient), GS-7

• (a) Experience. One year of creditable experience equivalent to the next lower grade level.
• (b) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (c) Demonstrated Knowledge, Skills, and Abilities. ( For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)

(5) Medical Records Technician (Coder-Inpatient), GS-8 (Full Performance Level)

• (a) Experience. One year of creditable experience equivalent to the next lower grade level.
• (b) Assignment. This is the journey level for this assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (c) Demonstrated Knowledge, Skills, and Abilities. (For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)

References: VA Handbook 5005/122 Part II, Appendix G-57, Medical Record Technician Qualification Standard.

The full performance level (FPL) of this vacancy is GS-08.

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.).